This is the accessible text file for GAO report number GAO-09-26
entitled 'Foster Care: State Practices for Assessing Health Needs,
Facilitating Service Delivery, and Monitoring Children's Care' which
was released on February 6, 2009.
This text file was formatted by the U.S. Government Accountability
Office (GAO) to be accessible to users with visual impairments, as part
of a longer term project to improve GAO products' accessibility. Every
attempt has been made to maintain the structural and data integrity of
the original printed product. Accessibility features, such as text
descriptions of tables, consecutively numbered footnotes placed at the
end of the file, and the text of agency comment letters, are provided
but may not exactly duplicate the presentation or format of the printed
version. The portable document format (PDF) file is an exact electronic
replica of the printed version. We welcome your feedback. Please E-mail
your comments regarding the contents or accessibility features of this
document to Webmaster@gao.gov.
This is a work of the U.S. government and is not subject to copyright
protection in the United States. It may be reproduced and distributed
in its entirety without further permission from GAO. Because this work
may contain copyrighted images or other material, permission from the
copyright holder may be necessary if you wish to reproduce this
material separately.
Report to the Chairman, Subcommittee on Income Security and Family
Support, Committee on Ways and Means, House of Representatives:
United States Government Accountability Office:
GAO:
February 2009:
Foster Care:
State Practices for Assessing Health Needs, Facilitating Service
Delivery, and Monitoring Children's Care:
Foster Care:
GAO-09-26:
GAO Highlights:
Highlights of GAO-09-26, a report to the Chairman, Subcommittee on
Income Security and Family Support, Committee on Ways and Means, House
of Representatives.
Why GAO Did This Study:
Providing health care services for foster children, who often have
significant health care needs, can be challenging. The Administration
for Children and Families (ACF) oversees foster care, but state child
welfare agencies are responsible for ensuring that these children
receive health care services, which are often financed by Medicaid. In
light of concerns about the health care needs of foster children, GAO
was asked to study states’ efforts to improve foster children’s receipt
of health services. This report has four objectives. It describes
specific actions that some states have taken to (1) identify health
care needs, (2) ensure delivery of appropriate health services, and (3)
document and monitor the health care of children in foster care. It
also describes the related technical assistance ACF offers to states.
To address these objectives, GAO selected 10 states and interviewed
state officials and reviewed related documentation regarding the nature
and results of the states’ practices. To describe ACF’s technical
assistance, GAO interviewed officials and reviewed documents from ACF,
states, and relevant technical assistance centers.
What GAO Found:
To identify the health needs of children entering foster care, all 10
states we studied have adopted policies that specify the timing and
scope of children’s health assessments, and some states use designated
providers to conduct the assessments. All of the states we selected for
study required physical examinations, most states we studied required
mental health and developmental screens, and several of them required
or recommended substance abuse screens for youth shortly after entry
into foster care. Preventive health examinations for foster children
were required at regular intervals thereafter, in line with states’
Medicaid standards. Limited research has suggested that having
assessment policies and using designated providers who have greater
experience in the health needs of foster children may permit fuller
identification and follow-up of children’s health care needs.
To help ensure the delivery of appropriate health care services, states
have adopted practices to facilitate access, coordinate care, and
review medications for children in foster care. Some states used
specialized staff to quickly determine Medicaid eligibility; others
issued temporary Medicaid cards to prevent delays in obtaining
treatment. In addition, certain states had increased payments to
physicians serving children in foster care to encourage more physicians
to provide needed care. Nurses or other health care managers were given
roles in coordinating care to help ensure that children received
necessary health care services. Six states we studied also reported
monitoring the use of various medications, including psychotropic
medications intended for the treatment of mental health disorders.
To document and monitor children’s health care, several states we
studied had shared data across state programs and employed quality
assurance measures, such as medical audits, to track receipt of
services. One state has developed a foster care health “passport” that
electronically compiles data from multiple sources, including the
state’s immunization registry, and this passport can be accessed and
updated by responsible parties through a secure Web site. Other states
used electronic databases to obtain more complete and timely medical
histories than otherwise available but provided more limited access to
these and continued to update them through use of paper records.
ACF’s network of 25 technical assistance centers is intended to improve
state performance in meeting children’s needs, including their health
care needs, by increasing the capacity of state agencies to ensure
safety, wellbeing, and availability of permanent homes for children in
their care. According to ACF officials, the centers are not intended to
provide medical expertise, but to help state child welfare agencies
collaborate with others involved with health programs. One center in
ACF’s network focuses exclusively on children’s mental health and
several others have also assisted in identifying some practices to
improve the health of children in foster care. Five of the centers are
newly funded and are expected to provide long-term help in implementing
plans to improve agency performance in meeting children’s needs.
What GAO Recommends:
GAO did not make any recommendations in this report. In commenting on
this report, Health and Human Services provided additional information
on its technical assistance efforts and technical comments which have
been incorporated as appropriate.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-09-26]. For more
information, contact K. E. Brown, 202-512-3674, brownke@gao.gov or C.
Bascetta, 202-512-7114, bascettac@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Specific Requirements for Health Assessments--and Using Designated
Providers to Conduct Them--Are Employed to Identify Children's Health
Care Needs:
Practices to Enhance Access to Services, Coordinate Care, and Monitor
Use of Medications Are among Efforts to Ensure Delivery of Health Care
to Foster Children:
Mechanisms for Data Management and Quality Assurance Address Challenges
to Documenting and Monitoring Children's Health Care:
ACF Offers States Health-Related Technical Assistance as Part of Its
Broader Efforts to Improve Delivery of Services:
Agency Comments and Our Evaluation:
Appendix I: Selection of States and Practices for GAO Review:
Appendix II: Comments from the Department of Health and Human Services:
Appendix III: GAO Contacts and Staff Acknowledgments:
Related GAO Products:
Tables:
Table 1: Findings of ACF Reviews with Respect to Common Challenges
States Faced in Meeting Children's Health Needs:
Table 2: Number of EPSDT Screens for Medicaid-Enrolled Children in
Selected Age Groups, by State:
Table 3: Examples of States' Approaches to Using Designated Providers
for Physical Health Assessments:
Table 4: Centers in ACF's Training and Technical Assistance Network
That Have Provided Assistance Related to Foster Children's Health Care
through 2008:
Table 5: Characteristics of States Contacted for GAO's Review:
Figures:
Figure 1: Steps Typically Involved in Addressing Health Needs of
Children in Foster Care:
Figure 2: Four Phases of the Initial Round of the CFSR Process:
Figure 3: State Data Systems Used by One or More State Child Welfare
Agencies to Develop the Health History of Children in Foster Care:
Abbreviations:
AAP: American Academy of Pediatrics:
ACF: Administration for Children and Families:
AIDS: Acquired immune deficiency syndrome:
CBO: Congressional Budget Office:
CFSR: Child and Family Services Reviews:
CMS: Centers for Medicare & Medicaid Services:
EPSDT: Early and Periodic Screening, Diagnosis, and:
Treatment:
HHS: Department of Health and Human Services:
HIV: Human immunodeficiency virus:
HRSA: Health Resources and Services Administration:
PIP: Program improvement plan:
SAMHSA: Substance Abuse and Mental Health Services Administration:
SCHIP: State Children's Health Insurance Program:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
February 6, 2009:
The Honorable Jim McDermott:
Chairman:
Subcommittee on Income Security and Family Support:
Committee on Ways and Means:
House of Representatives:
Dear Mr. Chairman:
Some of our nation's most vulnerable children are those who have been
removed from their homes and placed in foster care, often due to abuse
or neglect. Of the nearly 500,000 children in foster care at the end of
fiscal year 2007, 80 percent are estimated to have significant health
care needs, including chronic health conditions, developmental
concerns, and mental health needs. Treatment for the health care needs
of children in foster care is generally financed through states'
Medicaid programs.[Footnote 1] In addition to the extent of foster
children's health care needs, the disruptions associated with foster
care--such as having to leave home and experiencing several changes in
placement--may increase the challenges of ensuring that these children
receive health care services. However, conditions left untreated can
impede children's ability to realize their potential or become self-
sufficient later in life.
States are responsible for ensuring that children in foster care
receive necessary health care services. The Administration for Children
and Families (ACF) within the Department of Health and Human Services
(HHS) provides funding for state child welfare programs, including
foster care. In exchange for this funding, states agree to meet basic
federal requirements.[Footnote 2] However, they also have flexibility
in how they design and implement their programs. In its past reviews of
state agencies' performance, ACF determined that children under agency
supervision, including those in foster care, may not all receive
appropriate physical or mental health care services. For example, ACF
found that about 30 percent of children sampled either did not have
their health needs assessed or did not receive treatment during the
period reviewed. In these cases, states were required to develop and
implement improvement plans, and ACF monitored their implementation.
In October 2008, Congress expanded the federal requirements related to
foster children by mandating that states explicitly plan for the
ongoing oversight and coordination of health care services for children
in foster care.[Footnote 3] The state practices described in this
report, although in use before the expansion of federal requirements,
address some of the new requirements and, thus, may be helpful to other
states as they consider changes in their plans. Specifically, this
report addresses four objectives. It describes practices that selected
states have adopted to address the challenges of (1) identifying health
care needs, (2) ensuring delivery of appropriate health services, and
(3) documenting and monitoring the health care of children in foster
care. In addition, the report describes the technical assistance that
ACF offers states to help improve their performance in providing for
the health care needs of these children.[Footnote 4]
To address these objectives, we selected 10 states for in-depth study
based on the information they provided and the variations they
represented in geographic location, foster care caseload, and child
welfare administrative structures. The 10 states selected were
California, Delaware, Florida, Illinois, Massachusetts, New York,
Oklahoma, Texas, Utah, and Washington. (For more information on our
state selection, see appendix I.) We conducted site visits in three of
these states to describe state practices in context and gather views of
multiple stakeholders, such as state child welfare officials, health or
Medicaid officials, health care providers, foster parents, and in two
cases (Cook County, Illinois and New York City), the views of child
welfare personnel in major metropolitan areas. In our interviews with
officials of the seven remaining states, conducted by telephone, we
focused primarily on interviewing child welfare and Medicaid officials
regarding certain practices that state agencies identified.[Footnote 5]
We cannot generalize the results of our review from the 10 states we
selected to all states. Although we did not examine the actual
operation of every practice, we reviewed information about states'
practices through such means as discussions with researchers,
advocates, and other parties who had knowledge of these states' foster
care programs and, where available, we also collected and evaluated
research, state data, and other information on the effectiveness of the
practices adopted. In addition, we reviewed relevant federal laws,
policies, and guidance and research literature on the physical and
mental health needs and treatment of children in foster care. To obtain
information on ACF's provision of technical assistance, we reviewed
documents and interviewed officials at ACF and six centers
participating in ACF's network of technical assistance providers,
including the two centers jointly funded by ACF and HHS's Substance
Abuse and Mental Health Services Administration (SAMHSA). Our work was
designed to describe specific state and federal practices, not to
assess compliance with statutory or regulatory requirements. We
conducted our work from November 2007 to January 2009, in accordance
with all sections of GAO's Quality Assurance Framework that are
relevant to our objectives. The framework requires that we plan and
perform the engagement to obtain sufficient and appropriate evidence to
meet our stated objectives and to discuss any limitations in our work.
We believe that the information and data obtained, and the analysis
conducted, provide a reasonable basis for any findings and conclusions.
Results in Brief:
To identify the health needs of children, the states we studied
generally reported adopting policies that specified the timing and
scope of children's health assessments and, in some cases, also
employed designated providers to conduct these assessments. These
assessment features were intended to increase the likelihood of more
complete identification and follow-up of children's needs. Although ACF
had not imposed specific requirements for health assessments, the 10
states we selected for study required that children have a general
physical--often referred to as a well-child exam--within 30 days of
entering foster care, in line with recommendations from professional
associations. Most of these states also required that children's mental
health and developmental status be screened after entry, and several of
the states we selected for study cited screening for substance abuse.
The 10 states also required preventive health examinations at regular
intervals thereafter, in line with state Medicaid standards. To conduct
the assessments, some states used specially selected, trained, or
dedicated personnel to increase the likelihood that the children
received appropriate health care services. Limited research associates
the existence of specific assessment policies or use of specialized
personnel with higher rates of screening and referral than occur when
policies are not specific or personnel have no specific training.
Similarly, some state officials indicated that such assessment
policies, including the use of designated providers, have allowed them
to provide follow-up treatment more quickly than before these practices
were in place.
To ensure the delivery of appropriate health services, most states we
studied reported adopting one or more practices to facilitate access to
services, coordinate health care, and review medications for children
in foster care. These practices were intended to ensure that children's
health services were not only delivered in a timely way, but in a
consistent and complementary way across each step of the health care
delivery process. In one case, a state used specialized staff to ensure
that children in foster care were quickly reviewed for Medicaid
eligibility. Other efforts included increasing payment rates to
physicians for children in foster care to encourage more physicians to
provide needed care. With regard to coordination of care, state
practices included using nurses or other health care managers to help
ensure that children in foster care received necessary health care
services. In addition, several of the selected states identified
practices related to monitoring the use of psychotropic medications--
drugs commonly used for the treatment of mental health disorders--owing
to their effects on thought, behavior, or mood. For example, one state
requires a review of prescriptions in certain circumstances, such as
when multiple psychotropic medications are prescribed at the same time.
Officials in this state reported that after the policy took effect,
there was a decrease in the number of children in foster care who were
prescribed multiple psychotropic medications.
To document and monitor children's health care, some states we studied
reported having data management practices that included sharing health
care data across programs, and three states and a major city within
another state pointed to various quality assurance mechanisms to track
receipt of services. Data sharing with Medicaid and other data sources
has helped some states we studied develop and maintain health records.
In one state, these data sharing efforts include a foster care health
"passport" that electronically compiles data on a specific child from
multiple data systems, such as immunization records and data on
prescription medications. This system allows for continuous updating at
many points of care and permits access by multiple parties with
decision-making responsibility for the child's health. Most state child
welfare agencies we contacted reported using a combination of
electronic and paper-based data sharing to obtain information other
state agencies have compiled on children prior to their entry into
foster care to provide more complete and timely medical histories than
are otherwise available. However, these states provided more limited
access to these data, and updates typically relied on the exchange of
paper reports about medical visits and their results among doctors,
foster parents, and caseworkers. In addition, the three states we
visited and one major city reported having quality assurance activities
that could be used to help monitor the receipt of services for children
in foster care. For example, officials of some states we studied cited
specialized case reviews focusing on children's receipt of health care
services as supports in monitoring performance in meeting the health
needs of children in their care.
ACF supports a network of 25 technical assistance centers to help state
child welfare agencies improve their capacity to meet children's needs,
including their health care needs. ACF officials explain that they do
not expect the centers to provide technical assistance regarding
medical services, but instead to help child welfare agencies carry out
their broader mission to ensure the safety, wellbeing, and attainment
of permanent homes for children in their care. With respect to the
health of children in foster care, ACF officials stated that this may
involve helping child welfare agencies work collaboratively with other
agencies that provide health care services, including other federally
and nonfederally funded public and nonprofit programs. One of ACF's 25
centers focuses exclusively on children's mental health, and several
other centers have also assisted in identifying some practices designed
to improve the health of children in foster care. Included among ACF's
centers are five new centers that are due to become operational in 2009
and are expected to provide in-depth, long-term assistance in
implementing plans to improve agency performance in meeting children's
needs.
We provided a draft of this report to HHS for its comment. The agency
provided some additional information on its technical assistance to
state foster care agencies, particularly through collaboration between
ACF and SAMHSA in efforts to assist states to address health issues
such as mental health and substance abuse that may affect children in
foster care. HHS's comments are reprinted in appendix II. HHS also
provided technical comments, which we considered and incorporated as
appropriate.
Background:
Children in foster care tend to exhibit more numerous and serious
medical conditions than other children, including mental health
problems. Foster care begins when children are removed from their
parents or guardians and placed under the responsibility of a state
child welfare agency. Removal from the home can occur for several
reasons. For example, parental violence, substance abuse, severe
depression, or incarceration may have led to the children's removal
from the home. Other children and youth are referred when their own
behaviors or conditions are beyond the control of their families or
pose a threat to themselves or the community.
The realities of foster care may further contribute to the challenges
in meeting these children's health care needs. Once children are
removed from their homes, obtaining information on their health status
and health history from their parents or guardians may be challenging.
Also, children often move to several different foster homes or
treatment facilities during the course of their stay in foster care,
which may result in having different health care providers. Changes in
placement pose significant challenges for agencies, foster parents, and
providers with regard to providing continuity of health care services
and maintaining uninterrupted information on children's medical needs
and course of treatment.
Finally, in addition to specific characteristics or circumstances that
complicate their care, children in foster care encounter some health
care challenges in common with other health care users. Child welfare
agencies generally expect that foster parents or other caregivers will
recognize when children need medical attention and obtain the needed
health services, but such services may be in short supply or difficult
to access because of a lack of providers who serve Medicaid patients--
particularly for some specialties or geographic areas. Children
entering foster care may lack medical care prior to entry, and children
with prior medical care may have experienced disruptions in care,
changes in providers, and have missing or incomplete records.
Figure 1 illustrates the steps that are typically involved in
addressing health needs of children in foster care.[Footnote 6]
Figure 1: Steps Typically Involved in Addressing Health Needs of
Children in Foster Care:
This figure is a flowchart showing the steps typically involved in
addressing health needs of children in foster care.
[Refer to PDF for image]
Source: GAO analysis; images, Art Explosion (clip art).
[End of figure]
State and Federal Funding for Children in Foster Care:
All state child welfare agencies receive federal funds from ACF for
children in foster care under two parts of title IV of the Social
Security Act. The larger source of federal funds, under title IV-E,
provides open-ended reimbursement for a portion of states' foster care
expenses for children meeting federal eligibility criteria, who
represented about 43 percent of children in foster care in
2006.[Footnote 7] Title IV-E provided $4.8 billion to states in 2007
for the federal share of the expense of housing and feeding these
children.[Footnote 8] States cover the remaining costs and 100 percent
of the costs to house and feed children in foster care who do not meet
federal eligibility criteria. State child welfare agencies also receive
funds under title IV-B to provide services to children in foster care
and to those remaining in their homes for the purpose of preventing
conditions leading to the need to remove children from their
homes.[Footnote 9] In 2007, about $700 million was available under
title IV-B. State child welfare agencies cannot use title IV-E or most
IV-B funds for the direct provision of health care services. Limited IV-
B funds may be used for some health care services but are intended
primarily for the support and preservation of families, rather than for
children in foster care.[Footnote 10] Foster children who meet title IV-
E eligibility criteria, on the other hand, are explicitly identified as
a group that is eligible for coverage under Medicaid.
As a condition of receiving federal funds, state child welfare agencies
must agree to meet certain federal requirements, including requirements
related to the health of children in foster care. Under both titles IV-
B and IV-E, states must submit plans to ACF that contain a number of
statutorily required elements. For title IV-E, state agencies must have
a written case plan for each child that includes specific health
information, such as records of immunizations and medications, to be
shared with foster care providers at the time of placement. The
agencies must also have standards to ensure that children are provided
services to protect their safety and health. Because these standards
have not been further defined in statute or regulation, states have
some flexibility with respect to their form and content. For safety and
health standards, some states have cited standards for licensing foster
care facilities, training foster care parents, or credentialing staff.
In recent years, Congress has twice amended title IV-B, subpart 1 to
add new state plan requirements related to the health of children
served by child welfare agencies. Congress initially required that
state plans describe the involvement of physicians and other medical
professionals in the assessment and treatment of children in foster
care.[Footnote 11] This requirement was effective with state plans
approved by ACF in 2007. In October 2008, as we completed our review,
Congress further amended title IV-B, subpart 1 to require state
agencies to develop plans for the ongoing oversight and coordination of
health care services for children in foster care.[Footnote 12] This new
requirement expanded on the earlier requirement by mandating that the
agencies include in their plans schedules for initial and follow-up
health screenings that meet reasonable standards of medical practice;
steps to ensure continuity of health care services, which may include
the establishment of a medical home--a primary health care provider or
group--for every child in care; oversight of prescription medications;
and information on how children's needs identified through screenings
will be monitored and treated and how their medical information will be
updated and appropriately shared--as for example, by using electronic
health records. These requirements apply to all children in foster
care, regardless of whether or not the children meet federal
eligibility criteria.
Federal Oversight and Technical Assistance:
Starting in 2001, ACF took a new, results-oriented approach to its
oversight of state child welfare programs, focusing on whether children
and their families served by these programs achieved positive outcomes.
This oversight effort involved four phases of Child and Family Services
Reviews (CFSR), as shown in figure 2. ACF expects to complete the final
phase of the initial round of CFSRs in 2009.
Figure 2: Four Phases of the Initial Round of the CFSR Process:
This figure is a chart showing the following data:
Phase I:
State develops a self-assessment.
1. State and ACF review and correct statewide data profile.
2. State conducts focus groups and surveys and engages stakeholders and
staff.
Result:
ACF and state use statewide assessment information to select two
locations for on-site review. (Third location is state's largest
metropolitan area).
Phase II (6-7 months later):
ACF conducts its week long on-site review.
1. ACF draws a sample of cases and state prepares files from up to 65
cases.
2. State and ACF select and train review team.
3. Review team conducts file review and interviews stakeholders.
Result:
ACF prepares a final report based in part on the findings of the on-
site review and releases this report to the state.
Phase 3: (within 90 days after report release):
State develops program improvement plan (PIP).
1. State and ACF negotiate benchmarks and action steps.
Result:
ACF approves PIP, and state submits quarterly reports to ACF for
monitoring.
Phase 4: (2 years after PIP approval):
State completes PIP implementation.
Result:
ACF assesses the state's achievements against negotiated benchmarks and
determines whether or not financial penalties apply.
[Refer to PDF for image]
Source: GAO analysis.
[End of figure]
In the second phase of the initial round of the reviews completed in
2004, ACF identified significant performance challenges, particularly
with respect to meeting children's mental health needs.[Footnote 13]
ACF assessed state child welfare agency performance on 45 indicators
across a wide range of areas, such as children's safety and statewide
information systems. On the two health indicators addressing physical
and mental health, ACF identified 20 states as showing strengths in
providing services to meet children's physical health needs, and 4
states also showed strengths in meeting the mental health needs of
children in foster care and children remaining in their homes under
agency supervision.[Footnote 14] Nearly all states were required to
implement program improvement plans because they did not show strengths
in physical health, mental health, or both. ACF is required by statute
to offer technical assistance, to the extent feasible, to help such
states develop and implement plans to improve outcomes for children,
including health outcomes. When ACF determines that a state has not met
the jointly developed goals and action steps identified in these plans
within 2 years of approval of the improvement plan, ACF regulations
specify that it will withhold a portion of the state's grant
funds.[Footnote 15] In the course of its oversight, ACF identified
several challenges that states faced in meeting the health needs of
children in their care, as summarized in table 1.
Table 1: Findings of ACF Reviews with Respect to Common Challenges
States Faced in Meeting Children's Health Needs:
Physical health: Number of physicians and dentists in the state willing
to accept Medicaid is not sufficient to meet the need.[A];
Mental health: * There is a lack of mental health services for children
in the state.
Physical health: The state agency is not consistent in conducting
adequate, timely health assessments;
Mental health: * The state agency is not consistent in conducting
mental health assessments.
Physical health: The state agency is not consistent in providing
children with preventive health or dental services;
Mental health: [Empty].
Source: ACF, Summary of the Results of the 2001 - 2004 Child and Family
Services Reviews, p.10, [hyperlink,
http://www.acf.hhs.gov/programs/cb/cwmonitoring/results/index.htm]
(accessed on Nov. 21, 2008).
[A] See GAO, Medicaid: Extent of Dental Disease in Children Has Not
Decreased and Millions Are Estimated to Have Untreated Tooth Decay,
[hyperlink, http://www.gao.gov/products/GAO-08-1121 (Washington, D.C.:
Sept. 23, 2008)].
[End of table]
Medicaid and Health Care Services for Children in Foster Care:
Medicaid is the primary health care funding source for most children in
foster care.[Footnote 16] The Medicaid program is administered at the
federal level by the HHS's Centers for Medicare & Medicaid Services
(CMS) and is jointly financed by the states and the federal government.
All state Medicaid agencies receive federal funds for the Medicaid
program under title XIX of the Social Security Act. Within broad
parameters set by federal statute and regulation, state Medicaid
agencies are responsible for determining eligibility and establishing
the services and payments offered. Although many coverage, eligibility,
and administrative decisions are left to individual states, the federal
government sets certain requirements for state Medicaid programs, such
as coverage of certain screening and treatment services. Children who
meet federal eligibility criteria for IV-E foster care are required to
be covered by state Medicaid programs under federal law.[Footnote 17]
In addition, states have chosen to extend Medicaid coverage to other
children in foster care.[Footnote 18] In 2004, Medicaid expenditures
for children in foster care exceeded $5 billion.[Footnote 19]
Children in foster care who are enrolled in Medicaid may receive
services through one of two distinct service delivery and financing
systems--managed care and fee-for-service. Under a capitated managed
care model, states contract with a managed care organization and
prospectively pay the plans a fixed monthly fee per patient to provide
or arrange for most health services. Plans, in turn, pay providers. In
the traditional fee-for-service delivery system, the Medicaid program
reimburses providers directly and on a retrospective basis for each
service delivered.[Footnote 20]
States are required to offer certain screening and treatment services
to children enrolled in Medicaid.[Footnote 21] Termed Early and
Periodic Screening, Diagnostic, and Treatment services (EPSDT), these
screenings must include, but are not limited to, a comprehensive health
and developmental history, a comprehensive unclothed physical exam,
appropriate immunizations, laboratory tests, and health education. The
required services include vision, dental, hearing, and services for
other conditions discovered through screenings, regardless of whether
these services are typically covered by the state's Medicaid program
for other beneficiaries. The state Medicaid agencies establish
standards for the timing and frequency of these screening and treatment
services and set their own payment rates for fee-for-service providers
of these services. Federal regulations require that EPSDT screening
services be provided in accordance with reasonable standards of medical
and dental practice determined by the state after consultation with
recognized medical and dental organizations involved in child health
care.[Footnote 22]
In addition to EPSDT, states may choose to offer optional Medicaid
benefits, such as rehabilitative services and targeted case management
for children in foster care. States have used the rehabilitative
services option for children in foster care who have mental or
developmental problems as a means of providing a wide range of services
designed to help them achieve their highest level of functioning.
States have used targeted case management in order to provide case
management services to a defined group of Medicaid-eligible
individuals, such as children in foster care.[Footnote 23] Such case
management activities have included assessing a child's needs,
developing plans to meet those needs, referring a child to services,
monitoring the receipt of such services, and ensuring any necessary
follow-up care.
Federal Medicaid funds are available for a portion of case management
activities, as long as funds are not available from other programs or
from other entities, such as other insurers, that would be legally
obligated to pay for such services.[Footnote 24] However, concerns
exist that Medicaid funds have been inappropriately used,[Footnote 25]
and CMS has denied payment for services when funds were available from
other programs, such as Title IV-E.[Footnote 26] In 2007, CMS issued
rules--an interim final rule for case management services and a
proposed rule on Medicaid program coverage for rehabilitative services-
-that further defined the use of Medicaid funds for these benefits for
children in foster care.[Footnote 27] However, in 2008, Congress passed
and the President signed into law a moratorium on certain aspects of
the rules that remains in effect until April 1, 2009.[Footnote 28]
Other HHS Agencies:
In addition to ACF and CMS, other agencies within HHS have roles in
sustaining the health of foster children through supporting research,
providing grants, or offering technical assistance that may assist with
providing necessary health care services to children in foster care, as
shown below:
* The Agency for Healthcare Research and Quality is responsible for
supporting research designed to improve the quality of healthcare,
reduce its costs, address patient safety and medical errors, and
broaden access to essential services;
* the Health Resources and Services Administration (HRSA) administers
programs related to maternal and child health, as well as services
specific to particular conditions, such as human immunodeficiency virus
and acquired immune deficiency syndrome (HIV and AIDS); and:
* SAMHSA funds programs and services for individuals--as well as their
families and communities--who suffer from or are at risk for substance
abuse or mental health disorders.
Specific Requirements for Health Assessments--and Using Designated
Providers to Conduct Them--Are Employed to Identify Children's Health
Care Needs:
To help facilitate the timely identification of foster children's
health care needs, all 10 states we examined had adopted specific
policies with regard to the timing and scope of assessments, and 4 of
these states also reported using designated providers to conduct the
assessments. The policies generally call for assessments shortly after
children enter care and take one of two forms: (1) a two-stage
assessment comprised of an initial screening followed by a
comprehensive assessment or (2) a single comprehensive assessment. Most
states we selected for study included a requirement for screening of
children's mental health and developmental needs, and most of the
states we studied cited substance abuse screenings. Researchers and
state officials have suggested that having designated providers conduct
assessments may improve the quality and utility of assessment results.
State officials report that these assessment practices have allowed
them to make more appropriate and lasting placements of children in
foster care and also to provide follow-up treatment more quickly than
before these practices were in place. Some research also links specific
assessment policies to higher rates of follow-up.
Specific Requirements Can Ensure Timely, Appropriate Initial and
Comprehensive Assessments:
While federal law did not specifically require assessments before
fiscal year 2009, the 10 states we reviewed had made assessments of
children's physical health mandatory for all children entering care, as
recommended by medical and other professional associations.[Footnote
29] Because children often enter foster care with serious health
conditions and, at times, without easily accessible medical histories,
it is important to identify their health needs as quickly as possible.
Health or developmental status may be a critical factor in determining
the appropriate placement and level of care for children, as in the
case of children with HIV or significant behavioral problems. Where
there are explicit and comprehensive policies mandating assessments of
all children entering care, greater percentages of children are likely
to be assessed, according to a survey of a nationally representative
sample of child welfare agencies.[Footnote 30] Further analysis of
these survey data showed that agencies with comprehensive developmental
screening policies were more likely to evaluate children, refer them to
early intervention agencies, and engage in joint planning of health
care services.[Footnote 31]
Officials from the 10 states we reviewed reported using two general
approaches to conducting assessments, but all required some health
assessment within 30 days of a child's removal from his or her home.
Florida, Illinois, Massachusetts, and New York generally conduct
screenings or assessments in two stages: (1) an initial screening
within 24 hours to 7 days to check for immediate health needs and (2) a
later, fuller assessment within 30 days of entry into foster
care.[Footnote 32] Some state officials expressed the view that waiting
a while for the fuller assessment may give children the opportunity to
adjust to their changed circumstances and for this reason may offer
providers a more accurate picture of the children's health.
Additionally, they noted that assessments may be lengthy and require
significant time to complete. For example, Florida officials explained
that their comprehensive assessment of mental health, development, and
substance abuse takes 20 hours to complete, double the amount of time
the state previously allotted in order to cover all necessary aspects
of care. A second approach to identifying children's health care needs-
-used by California, Delaware, Oklahoma, Texas, Utah and Washington--
invokes a one-stage assessment process mandating that it be completed
within 14 to 30 days of entry into foster care depending on the
state.[Footnote 33] Utah officials explained that the state dropped its
earlier requirement for an initial screening followed by another
assessment, in part because the results were duplicative. However, the
state expects caseworkers to be alert to urgent health needs and
arrange treatment as needed. The state has written guidelines advising
caseworkers that if there is any sign of abuse or neglect or if the
child is ill, the child should be seen by a health care provider within
24 hours.
Once a child enters foster care and receives an initial assessment,
state foster care policies in most of the states we selected for study
required that ongoing assessments follow the schedules established by
state Medicaid agencies for children's screening, which are based on
the children's age or the time between routine checkups.[Footnote 34]
Six of the 10 states we selected for our study called for children in
foster care to receive at least annual screening, either under a
separate health standard applicable to foster children or because their
EPSDT standard for all Medicaid enrollees called for at least annual
screenings, consistent with the 2008 American Academy of Pediatrics'
recommendation on preventive pediatric care. See table 2 for a summary
of the number of EPSDT screens incorporated in the Medicaid EPSDT
standard for all children in the Medicaid programs in the 10 states we
reviewed.
Table 2: Number of EPSDT Screens for Medicaid-Enrolled Children in
Selected Age Groups, by StateA:
State: California[B];
Age group: Less than 1: 6;
Age group: 1-5: 6;
Age group: 6-14: 3;
Age group: 15-20: 1;
Age group: Total: 15.
State: Delaware;
Age group: Less than 1: 7;
Age group: 1-5: 8;
Age group: 6-14: 9;
Age group: 15-20: 6;
Age group: Total: 30.
State: Florida[C];
Age group: Less than 1: 7;
Age group: 1-5: 7;
Age group: 6-14: 7[D];
Age group: 15-20: 15-20: 6;
Age group: Total: 27.
State: Illinois[D];
Age group: Less than 1: 7;
Age group: 1-5: 7;
Age group: 6-14: 5;
Age group: 15-20: 3;
Age group: Total: 22.
State: Massachusetts;
Age group: Less than 1: 6;
Age group: 1-5: 7;
Age group: 6-14: 9;
Age group: 15-20: 6;
Age group: Total: 28.
State: New York;
Age group: Less than 1: 7;
Age group: 1-5: 8;
Age group: 6-14: 9;
Age group: 15-20: 15-20: 6;
Age group: Total: 30.
State: Oklahoma;
Age group: Less than 1: 5;
Age group: 1-5: 7;
Age group: 6-14: 4;
Age group: 4;
Age group: Total: 20.
State: Texas;
Age group: Less than 1: 5;
Age group: 1-5: 7;
Age group: 6-14: 7;
Age group: 15-20: 6;
Age group: Total: 25.
State: Utah;
Age group: Less than 1: 6;
Age group: 1-5: 7;
Age group: 6-14: 7;
Age group: 15-20: 6;
Age group: Total: 26.
State: Washington[E];
Age group: Less than 1: 5;
Age group: 1-5: 6;
Age group: 6-14: 5;
Age group: 15-20: 3;
Age group: Total: 19.
Source: GAO analysis of states' EPSDT screening requirements.
[A] Because some states used age categories in describing their
policies that did not align with those shown here, the distribution of
screens across age groups is an approximation, with no screen counted
more than once.
[B] California adopted a screening schedule based on an earlier
American Academy of Pediatrics screening schedule. According to state
officials, California is in the process of updating the state's
screening schedule to conform to the most recent American Academy of
Pediatrics screening schedule.
[C] Florida follows the 1999 American Academy of Pediatrics schedule,
which recommended a total of 27 screens. Florida Medicaid also
recommends check-ups at 7 and 9 years of age for "children at risk."
[D] Illinois recommends that health screening be provided to children
on a periodicity schedule based on acceptable medical practice
standards, such as the schedule recommended by the American Academy of
Pediatrics. The schedule above was provided by the Illinois Department
of Public Aid, now known as the Illinois Department of Healthcare and
Family Services, as a minimum guideline for children in the Medicaid
program. The Illinois Department of Children and Family Services
requires that children in foster care receive at minimum annual health
screenings between the ages of 6 and 21.
[E] The Washington EPSDT standard specifies annual screening for
children in foster care between the ages of 2 and 20.
[End of table]
In addition to policies requiring assessments of children's physical
health, 8 of the 10 states we studied also reported requiring screening
or assessments of children's mental and developmental health shortly
after entry into foster care. Research indicates that an estimated 30
to 60 percent of children in foster care may have chronic health
conditions, and the proportion estimated to have serious health care
needs rises to over 80 percent when behavioral, emotional, and
developmental concerns are included.[Footnote 35] Guidelines issued by
professional associations emphasize the importance of assessing mental
health and other behavioral health issues for children in foster care.
An analysis of the results of ACF reviews conducted between 2001 and
2004 found no evidence of policies requiring an assessment of
children's mental health in most states; in one state, stakeholders
noted that children did not get mental health assessments unless there
were problems observed.[Footnote 36] The ACF reviews have helped focus
attention on the mental health needs of children in foster care,
however, and we found that most of the 10 states we selected for study
had adopted policies to screen or assess the mental health and
development of children entering foster care. Most states we studied
had also adopted policies requiring or recommending screening youth
entering foster care for substance abuse. For example, Delaware
officials told us that--since February 2006--its initial health
screening has required the inclusion of a component alerting staff to
any mental health or substance abuse problems for all children 4
through 17 years of age. Other state policies varied in whether or not
they included specific time frames. For example, New York has no
mandatory time frame for its required mental health assessment,
although it is recommended that this be completed within 30 days of
placement. State guidance also varies on the tools used for the
assessments. In some states, such as Massachusetts, the steps taken by
individual health practitioners as part of either (1) the comprehensive
screening within the first 30 days or (2) in later Medicaid screenings
are considered sufficient to meet the policy requirements. In other
cases, states have adopted or are considering adopting specific
screening tools. For example, Utah reported the state had specified the
tools to be used in assessing the development of children ages 4 months
to 5 years. Officials in both California and Oklahoma reported they
were working to identify assessment instruments for the early
identification of children with mental health or developmental needs.
The Use of Designated Providers Can Increase the Thoroughness of
Physical and Mental Health Assessments:
Four states we studied reported using designated providers to perform
certain initial and comprehensive assessments, which some evidence
indicates can increase the consistency and thoroughness with which
children's physical and mental health needs are identified. Illinois,
for example, requires that children's initial health evaluations be
conducted by a network of hospital emergency rooms and clinics, while
subsequent assessments are generally conducted by a network of
community-and facility-based physicians, with foster parents permitted
to use others on request. We identified two studies that associated use
of designated or specialized health care providers for foster children
with higher rates of preventive and specialty care.[Footnote 37]
With regard to physical assessments, states that identified the use of
designated providers to perform initial screens and comprehensive
assessments reported that these providers functioned as part of a
network of providers, as primary providers in specific locations, or
both and, in some cases, that the use of such networks had enhanced the
numbers receiving assessments. For example, Florida reported that some
of its counties have focused on developing a network of trained
providers, while Oklahoma and Utah identified specific locations in
urban areas--such as clinics or hospitals--where some children could
receive assessments. In most cases, these initial providers could serve
as medical homes for the children they assessed. (See table 3 for more
information on how states use designated providers.) Some state
officials commented that the use of a specific network of physicians
also facilitated quality improvement efforts. For example, a physician
with Cook County's Healthworks program noted that the quality of health
assessments--once a subject of complaint from child welfare field
staff--had improved when assessments were channeled to a network of
specific providers that could be supported by targeted training
efforts. He noted that the health assessment for a child entering
foster care requires a more thorough, detailed approach and level of
documentation than that involved in a standard EPSDT well-child exam.
Table 3: Examples of States' Approaches to Using Designated Providers
for Physical Health Assessments:
State: Florida;
Description of approach: * Some counties within Florida use a network
of physicians to conduct initial screenings for children in foster
care;
* Such networks may serve as a medical home for children throughout and
beyond their stay in foster care.
State: Illinois;
Description of approach: * Illinois has a network of providers who
conduct initial health screenings, comprehensive health evaluations,
and ongoing primary care for all children in foster care, and some
comprehensive evaluation providers may serve as sources of continuing
care;
* Providers may be located in hospitals or clinics, with hospital
emergency rooms or clinics serving as the initial screening location
for children.
State: Oklahoma;
Description of approach: * Oklahoma uses primary care providers in
clinics in Oklahoma City and Tulsa to screen children for physical,
mental health, and dental needs, as well as any social needs;
* The clinic location can serve as a medical home for the child after
assessment.
State: Utah;
Description of approach: * Children entering custody with a medical
home are to be sent to their original provider for the comprehensive
health assessment;
* For children in foster care who do not have an identified medical
home, Utah uses providers located in a public health clinic in Salt
Lake City to provide initial screening and comprehensive health
assessments to local children in foster care;
* The clinic can serve as a medical home for the child after
assessment.
Source: GAO analysis of state interview responses, as of August 2008.
[End of table]
The states shown in the table as using designated providers elaborated
on their practices and, in some instances, noted specific strategies
that may contribute to providers' effectiveness:
* Illinois requires that the initial health screening be completed
within an hour of the child's arrival at the medical facility. Illinois
officials reported that appointments for the screening in Cook County
are arranged through a toll-free telephone service called HealthLine,
which is staffed around the clock by a child welfare contractor who can
obtain priority service for children so they do not experience lengthy
waits in hospital emergency rooms. Hospital emergency rooms are used
for many initial screenings because they are accessible outside of
normal business hours, but the comprehensive health assessments
generally take place in physicians' offices because they require more
time. Research on children enrolled in the Illinois program has shown
that these children experienced higher rates of preventive and
necessary specialty care than other children with similar socio-
economic characteristics who were not enrolled in the program. Although
the research did not evaluate the effectiveness of the program itself,
the researchers concluded that the increased attention and oversight of
the health care for the children enrolled in the program affected their
outcomes.[Footnote 38]
* Oklahoma officials noted that their clinic-based assessment process
began with a pediatrician who had experience working with children who
had been removed from their homes and placed into shelters. Concerned
about the continuity of care for children in these situations, this
pediatrician set aside particular times for children in foster care to
visit the clinic and see a familiar provider. A second clinic that was
opened in another large city is also under the medical direction of a
pediatrician familiar with the needs of children in foster care.
Officials told us they believe that children's health care benefits
when they are served by providers with knowledge of the foster care
population.
In addition to using designated providers for physical health screens
and comprehensive assessments, a few states reported using a mental
health specialist who worked with caseworkers to conduct assessments.
The use of specialists to conduct mental health screenings can be an
effective means of identifying children's mental health needs. One
study that surveyed a nationally representative sample of agencies
found that involving mental health specialists in assessments resulted
in a greater identification of mental health needs, as well as improved
follow-up care, than were received by children whose assessments did
not include a mental health specialist.[Footnote 39]
The mental health assessments used by states we selected varied. In
some cases, the assessments were comprehensive social assessments that
covered areas such as mental health, emotional health, school, work,
and community involvement. In other cases, the focus was narrower,
covering specific topics such as indicators of mental illness.
Washington officials reported that specialized social workers conducted
comprehensive assessments using standardized tools that assess several
aspects of social and mental health needs, including behavioral,
developmental, educational, family, and social issues.[Footnote 40] For
physical or mental health concerns identified during the screening that
require treatment, state officials indicated that the social workers
refer children to appropriate health care professionals.
Practices to Enhance Access to Services, Coordinate Care, and Monitor
Use of Medications Are among Efforts to Ensure Delivery of Health Care
to Foster Children:
To address the challenge of ensuring delivery of appropriate health
care services to children in foster care, several of the states we
selected for review adopted practices designed to facilitate access to
care, coordinate services, and review medications for children in
foster care. Practices relating to access to care included efforts to
hasten determination of Medicaid eligibility, implement financial
incentives for providers to serve children in foster care, and enhance
access to medical specialists for various subgroups of children. Care
coordination practices that the selected states identified employed
either nurses or other health care managers to help ensure that
children in foster care received necessary health care services.
Officials of specific states we contacted said that such care
coordination had increased rates of immunization, initial assessment,
and well-child visits. Finally, officials from six of the states we
studied pointed to policies that they had implemented requiring the
review of prescriptions for psychotropic medications commonly used to
treat mental health disorders for children in foster care.
Practices to Enhance Access to Care Include Streamlined Medicaid
Eligibility, Financial Incentives to Providers, and Strategies to
Obtain Specialty Care:
Among the states we studied that identified a practice state officials
believed noteworthy in enhancing access to care, some had identified
assigning certain staff--from their Medicaid offices or from their
child welfare offices--to ensure that children in foster care were
quickly reviewed for Medicaid eligibility. Because the removal of a
child from home can change his or her Medicaid eligibility status, some
states we contacted had taken steps to save time in certifying Medicaid
eligibility and facilitate new foster care beneficiaries' access to
providers. For example, Delaware had assigned two Medicaid staff to
foster care cases, while Florida, Utah, and Illinois used staff members
from the child welfare offices to determine eligibility for Medicaid.
Utah has a written agreement between the state child welfare and
Medicaid agencies that specifies that certain staff in Utah's Division
of Child and Family Services will determine Medicaid eligibility for
children in foster care. The purpose of this arrangement is to enhance
services to children and families, simplify administration, improve
accuracy, conserve state resources by avoiding duplication, and
maximize legitimate Medicaid funding. In Illinois, children coming into
foster care are presumed to be eligible for Medicaid. For purposes of
formal eligibility determination, Illinois officials reported that
using specialized staff members in the state child welfare agency's
central office to complete the determination had sped up the process.
Specifically, they reported that a process that once took 3 to 4 months
could now be completed within 4 weeks of issuance of the temporary
medical card. Florida officials also reported that their agreement that
staff from the child welfare department determine Medicaid eligibility
reduced the amount of time required to make these determinations from
18 days to within 24 hours.
Illinois and Washington are among the states that offer financial
incentives to providers who treat children in foster care, since
providers may be reluctant to serve children in foster care. In
Illinois, physicians serving children in foster care are paid a one-
time $15 fee to initiate a paper health passport to document the health
history and ongoing care of the child. Additionally, the state uses an
enhanced payment rate for initial health screenings conducted in
hospital emergency rooms.[Footnote 41] Washington officials reported
that the state increased its payments in November 2001 for medical
providers who conducted well-child examinations for children in foster
care. At the time, these rates were about twice the reimbursement rate
paid in other cases. State officials reported that since 2001, other
Medicaid rates--such as payments for EPSDT services--have also
increased, so that rates for foster care children are no longer twice
as high. However, the foster care rates remain equal to or
substantially greater than the standard Medicaid rates. In April 2008,
Washington officials told us that approximately two-thirds of children
received well-child examinations, up from about 17 percent before the
state increased the rates in 2001.
Utah, Illinois, and New York have instituted a variety of programs to
increase access to medical specialists or subspecialists. Under some
circumstances, obtaining specialty care can be difficult for Medicaid-
eligible children, and such efforts for children in foster care may be
even more difficult if the children have complex health needs or
changing placements. These states' efforts typically focused on
specific subgroups of children in foster care, such as those in rural
areas, those who need mental health services, and those who would
otherwise require institutional care.
* Children in Rural Areas: Utah and Illinois have efforts focused on
children living in rural areas where it may be harder to find a
pediatric health specialist or subspecialist. For example, Utah has
eight clinics to which multidisciplinary teams travel in order to
provide specialty services for children with special health care needs
across rural Utah. State officials told us that in some cases, children
are seen more quickly in these locations than in Salt Lake City.
Illinois officials reported transportation is available and sometimes
is used to get rural foster children to providers, including oral
dental surgeons, orthodontists, and child psychiatrists. Despite these
efforts, state child welfare officials cited a continuing challenge in
obtaining mental health and substance abuse services, and especially
child psychiatry for children in Medicaid and other publicly-funded
medical care, not just those in foster care. As a result, Illinois has
also begun to look at the use of telepsychiatry in one of its downstate
regions.[Footnote 42]
* Children Needing Mental Health Services: To address children who are
experiencing mental health crises, Illinois developed a psychiatric
crisis intervention program with a single, statewide 24-hour, 7-day-a-
week crisis hotline. When a person calls the crisis line, a mental
health provider is expected to reach the child in crisis within 90
minutes of the call to conduct a screening and determine if the child
requires psychiatric hospitalization. Following this decision, the
mental health provider is to continue to provide treatment and other
service interventions for a minimum of 90 days. State officials
reported that this program serves about 18,000 children per year,
including all children who receive Medicaid or other public funding for
medical care (not just those in foster care). Medicaid covers all the
services provided by this program, which began in 2004, on a fee-for-
service basis.
* Children Who Might Otherwise Require Institutional Care: With respect
to difficulty in accessing specialty services, New York launched a
program in early 2008 for children in foster care who have
developmental disabilities, serious emotional disturbances, and medical
problems that are so severe they would otherwise likely be in
restrictive and high-cost institutions. By making community-based
services available to a fixed number of these children, the state hopes
to help them function in family and community settings instead. New
York officials reported that when the program is fully implemented
after 2011, it will serve approximately 3,000 children in foster care.
Public Health Nurses and Other Health Care Managers Coordinate Care to
Help Ensure Health Services Are Delivered Appropriately:
Several states we studied discussed their development of the role of
health care managers with the goal of improving health care and health
outcomes for children in foster care. While all children in foster care
have caseworkers, they focus on issues related to the child's safety
and permanency and do not necessarily have medical expertise.
Typically, health care managers are nurses who are colocated with the
child welfare agency and work with the child's foster care caseworker.
Officials in California told us that the nurses are colocated in the
child welfare offices so they can easily talk directly to caseworkers.
These nurses may be able to more quickly spot gaps in care than foster
care caseworkers because they are trained to understand children's
health and developmental needs, they are able to communicate clearly
with health care providers, and they can provide medical guidance to
both foster care caseworkers and foster and biological parents. In some
states--such as California and Utah--each child is assigned a nurse,
while in other states--such as Illinois and Massachusetts--only those
children with specific or medically complex needs are individually
assigned to a nurse. In some states, public health nurses provided the
care coordination services for children in foster care, whereas in
Illinois, the state child welfare agency or a local contracting agency
served as health care manager. Some positive results in achieving
health-related goals for children in foster care had been documented
for a health care management effort in New York.[Footnote 43]
The specific services provided by health care managers varied in the
states we contacted, but usually included the development and
maintenance of the child's health history, medical case planning--that
is, identifying the child's medical needs and arranging for receipt of
medical services--and identification of medical professionals available
to provide services to children in foster care. For example, state
officials in Utah told us that the state has 29 Maternal and Child
Health agency nurses serving about 90 children each. The nurses may
provide medical, mental health, and dental consultation; identify the
child's primary care provider; place the child in the appropriate
health plan; gather, evaluate, and document the health history of each
child; track ongoing health care; and maintain an up-to-date medical
history on each child within an electronic database.[Footnote 44]
Officials in Utah reported that use of public health nurses has reduced
errors in transcribing information about medical history and ongoing
care into the state's electronic database. Utah officials also reported
that they find that biological parents are more comfortable talking
openly with the nurse, who they said biological parents tend to view as
an advocate rather than an adversary. According to data provided by
state officials, another result of the program is that more children
are getting their comprehensive assessments completed than before, and
more quickly than required. Specifically, Utah officials reported that
about 76 percent of children received these assessments in a timely
fashion in 2008, compared to 58 percent in 1998, before the program was
implemented. They further noted that these assessments are being
conducted in 18 days, on average, rather than taking the full 30 days
allowed by state requirements.
Health care managers may also provide other services. Caseworkers in
Illinois told us that in medically complex situations, families can be
assigned to a regional nurse who can provide recommendations and assist
a caseworker in communicating with the family on medical needs.
Similarly, in Massachusetts, staff told us that nurses in regional
offices provide consultation to staff regarding the medical needs of
all children and work with children who have difficult or complex
medical needs. In Illinois, officials at one of the privately-run case
management programs in Chicago became concerned about immunization and
well-child exam completion rates. As a result, they implemented a paper-
based reminder-recall system that gives foster parents, providers, and
caseworkers information about when and what medical services are
needed. Prior to the implementation of the reminder-recall system,
officials in one agency that had adopted it told us that 77 percent of
children had up-to-date immunizations and 44 percent had received
appropriate well-child visits. These officials reported that in 2007,
after implementation of this reminder-recall system, 96 percent
received appropriate immunizations and 90 percent had received well-
child care. We were told that the five community-based medical care
management agencies in Cook County used the reminder-recall
system.[Footnote 45] In addition, some counties outside of Cook County
have instituted a similar system.
New York conducted a formal evaluation of its health care management
project and found that such care coordination had a significant,
positive impact on many aspects of care, including the receipt of both
initial physical and dental assessments, access to nonpreventative
care, and health-related contacts between agency workers and foster
parents.[Footnote 46] However, funding was not available for the state
to continue this program when the initial pilot project was completed
and the project did not meet nonhealth and well-being related child
welfare goals, such as reducing the number of days spent in foster care
and increasing the likelihood of leaving foster care for a permanent
placement.
Policies Governing the Review of Psychotropic Medications Implemented
to Help Ensure Children in Foster Care Receive Appropriate Health Care:
Officials in six of the states we selected for interview identified
specific policies they had adopted to govern the review of psychotropic
medications intended for the treatment of mental health
disorders.[Footnote 47] An Illinois official noted that the use of
psychotropic medications is uniquely challenging for children in foster
care, given that foster children who change placements often do not
have a consistent person to plan treatment, offer consent, and provide
oversight. Most of the policies states identified require an extra
level of review beyond the person prescribing the medication, either by
state officials or local experts. Concerns have been expressed that
psychotropic medications have frequently not been tested for their
safety and efficacy with children, and one study of children in foster
care found that the most frequently prescribed medication was an
antipsychotic drug that had not been tested for use by children and
adolescents.[Footnote 48] Some research has also found that use of
psychotropic drugs by children in foster care is three to four times
greater than by other low-income children insured by Medicaid.[Footnote
49] Greater prevalence of use is not, by itself, evidence of
inappropriate use; children in foster care may be more likely to have
conditions for which the drugs are indicated. However, administrative
data from one state associated the introduction of its policy with
modest decreases in prescribing psychotropic drugs and declines in
specific patterns of prescribing, such as prescribing multiple drugs.
Texas has developed a policy that notes the importance of conducting a
health history, psychosocial assessment, mental status exam, and
physical exam before prescribing psychotropic medications. The policy
suggests that alternative interventions should generally be considered
before beginning the use of psychotropic medications and outlines
specific circumstances under which a case may require further
review.[Footnote 50] Data examining the percentage of children
prescribed a psychotropic medication for at least 60 days, the
percentage prescribed two or more medications concurrently from the
same drug class, and the percentage prescribed five or more medications
concurrently showed decreases from fiscal year 2004, before the new
policies were implemented, through fiscal year 2007.[Footnote 51]
Because of concerns raised about the appropriate use of psychotropic
medications, California requires judicial approval for their
administration to a foster child. The prescribing physician must make
the case to a juvenile court judge that the particular medication is
appropriate for the given child and that alternatives have been
considered. The Judicial Council of California has adopted rules of
court to implement this legal requirement. Specifically, these rules
require that an application be made to a juvenile court judge
requesting the use of psychotropic medication and that the application
include the signature of the physician to request the medication's use;
the child's diagnosis, the specific medication, and dosage recommended
for use; the anticipated benefits and possible side effects of the
medication; a list of other medications the child is taking, along with
a description of possible drug interactions; a description of other
treatment plans; and a statement that the child has been informed of
the recommended course of treatment with their responses. The court may
grant the application or may delegate that authority to the parent if
it is found that the parent poses no danger to the child and that the
parent has the capacity to understand the request. In an emergency, the
rules allow the administration of psychotropic medications without
court approval in accordance with existing law, but court approval must
be obtained within 2 days.
Other states have worked with universities and local experts to help
with the oversight of psychotropic medication use by children in foster
care. For example, Illinois has contracted with a university to provide
an independent review of each psychotropic medication request to ensure
safe and appropriate usage with children in foster care. The request is
forwarded to a board-certified child and adolescent psychiatrist who
reviews the information and determines whether to approve, deny, or
adjust the request. According to state officials, Florida has also
worked with a local university to develop a process whereby caregivers
of children in foster care receive a consultation with a physician
before psychotropic medications are prescribed. The state also has a
mandatory preconsent consultation for all children age 5 and under in
foster care. The state then tracks information about the medication,
such as the prescribing physician, medication, dosage, number of
refills, and its purpose. As a result, the state is able to determine
the number of children receiving certain types of medication and can
then identify areas where there might be concerns about inappropriate
use. Oklahoma and New York also work with experts to review and provide
training related to the use of psychotropic medications by children in
foster care.
Mechanisms for Data Management and Quality Assurance Address Challenges
to Documenting and Monitoring Children's Health Care:
To address the challenges of documenting and monitoring children's
health care, some states we studied shared health care data across
various state systems to acquire more complete medical histories and
used quality assurance mechanisms, such as medical audits or
specialized case reviews, to track receipt of services. Efforts to
share health care data generally focused on enhancing access to
existing health information among parties responsible for the health of
children in foster care while meeting requirements for data security
and privacy protection. For example, through data sharing with Medicaid
and other data sources, Texas has developed an electronic health
record--known as the Foster Care Health Passport--that can be viewed by
authorized individuals involved in the child's care through a secure
Web site. More commonly, states we studied identified initiatives that
also combined data from different sources but did not offer electronic
access or provide for any updating at the point of care, relying on
paper-based transfers of medical histories and providers' updates via
the foster parents. Quality assurance activities have also made use of
electronic systems as a means of monitoring the receipt of services for
children in foster care. These efforts can be important to ensuring
that individual children receive the appropriate level of services,
avoiding duplication of services such as immunizations, and ensuring
the receipt of needed services.
Data Sharing with Medicaid and Other Systems May Yield More Complete
Medical Information:
Some states share data with Medicaid and other state systems, such as
immunization registries, in order to obtain more complete medical
information than might otherwise be available as a child enters foster
care. Basic health information should be included in a written case
plan and provided to foster parents before children are placed with
them. Obtaining information that is important to a child's health
records can be a complex task, which may involve four or more separate
systems (see fig. 3). Additionally, information collected from parents
and caregivers may also be of assistance in understanding the needs of
a child.
Figure 3: State Data Systems Used by One or More State Child Welfare
Agencies to Develop the Health History of Children in Foster Care:
This figure is an image of a child's health care record, which should
contain the following: medicaid claims, immunization registry, health
provider's records, and pharmacy claims.
[Refer to PDF for image]
Source: GAO analysis; images, Art Explosion (clip art).
[End of figure]
States that pointed to records management systems as a means of
developing health history cited the use of an electronic health record-
-sometimes termed an electronic passport--or other efforts to combine
sources of information. Combining these sources of information is
important because few children enter foster care with records that
accurately identify their health providers, health conditions, or
receipt of services. Without these records, their health care may be
delayed until records are available, or their care may be compromised.
For example, officials in two states told us of cases in which health
providers had refused to provide specific treatments to children in
foster care because they did not know their histories or did not have
medical records available to prevent improper treatment. Similarly,
children may miss immunizations, receive duplicate immunizations, or
forego necessary medications.
Web-Based Electronic Passport Can Allow Access to Comprehensive Health
Information on Individual Children in Foster Care:
In April 2008, Texas began implementing an electronic passport to track
health data for 29,000 children in foster care.[Footnote 52] This
passport can be updated regularly and is accessed through a secure Web
site by foster parents, caseworkers, and health care providers who are
responsible for making health decisions on behalf of children.[Footnote
53] The Foster Care Health Passport is operated by a managed care
organization that is under contract with the state Medicaid agency.
Texas developed and implemented the Health Passport using funds from
the state and CMS. Officials told us that total funding data were not
readily available.
When a child enters the Texas foster care system, his or her electronic
health record is created by obtaining information from a variety of
sources. The Health Passport is initially populated with Medicaid and
State Children's Health Insurance Program (SCHIP) claims, including
pharmacy claims data from the past 2 years for children previously
enrolled in Medicaid or SCHIP. Officials told us that generally, data
from these sources are available for a majority, but not all, children
who enter foster care. Immunization records are entered through a data
sharing arrangement with the state's immunization registry. Once the
electronic health record is created, it can be electronically updated
with information on any health care services that were delivered by any
foster care health provider in the managed care organization's network.
Claims data are added when the claim is processed, which state
officials indicated could take a few weeks or months, noting that
providers have 90 days after a medical visit to submit a claim.
Services provided outside of the contractor's network must be added
manually through an online form mailed or faxed to the managed care
organization. Officials told us that the passport also records
behavioral health, dental, and vision services. Finally, officials
stated that information in the Health Passport remains accessible
statewide, even when the child's placement changes and the child moves
to new foster parents, localities, or health providers. When children
leave foster care, the electronic health record is printed out for the
child or his caregiver.
While the Health Passport has not been operational long enough to
determine its effectiveness, state officials told us that they are
working on baseline measures for several variables, such as well-child
outcomes, and have developed measures to assess the contractor's
performance.[Footnote 54]
Officials in several other states we contacted expressed an interest in
pursuing the development of an electronic health passport. For example,
Illinois uses several data systems to manage Medicaid, foster care, and
community health and preventive care for children, but the state is
working toward integrating data electronically from the many systems in
use, with the ultimate goal being the construction of an electronic
passport. Some obstacles to data sharing have included concerns about
privacy and security. As states look to sharing individuals' health
data to better serve and treat them, they are also implementing
standards governing the transmission of data, policies to ensure that
only authorized users have access to records, and provisions to protect
individuals' privacy. CMS has taken steps to provide assistance to
states on issues of security and privacy. Several of the states
included in this study cited practices they used to create medical
histories and agreements they have to address data security and privacy
issues.
Other Forms of Data Sharing Can Improve Access to Timely Health
Information:
Other forms of data sharing use and combine existing record-keeping
systems, usually through a combination of electronic matches and paper
exchange of data among doctors, foster parents, and the Medicaid or the
foster care agency, as shown in the examples below.
* Oklahoma officials noted that the state's efforts to obtain medical
information for children entering foster care centered on using
Medicaid claims data, which it has been doing on a statewide basis
since 2007. State officials reported that the project has been
particularly successful because over 90 percent of children entering
foster care had some prior Medicaid history and over 80 percent were
already on Medicaid when they entered the state's care. Officials noted
that the Medicaid claims data can provide information on developmental
assessments, immunizations, as well as the receipt of both physical and
mental health services.
* In Utah and Illinois, nurses enter children's health information into
the state child welfare agency's database. In Utah, public health
nurses who work in collaboration with child welfare workers provide
medical care coordination and record visits, diagnoses, and
prescriptions for children in foster care. The child welfare agency in
Illinois has a memorandum of agreement with its Medicaid agency to
share pharmacy claims data for purposes of identifying doctors
prescribing psychotropic medications without consent, and it also
electronically obtains immunization data on children in foster care
from an immunization registry. Both Utah and Illinois state officials
told us that they were in the process of creating an integrated system
that will store more complete electronic health records for children in
foster care. For example, Illinois child welfare officials reported
they were working with other state agencies to be able to pull data
from Medicaid claims and other sources.
* Massachusetts uses a combination of paper and electronic records.
They exchange medical information with foster parents and health care
providers on paper, which they then enter into an electronic database.
* An official with HHS's Agency for Healthcare Research and Quality
told us that health information exchanges in Colorado and Indiana are
being developed with federal demonstration grants that will include
foster children along with other patients. The HHS Inspector General
reported in August 2007 that at least 27 states are developing at least
partially electronic health records for Medicaid with funds from CMS.
These efforts may extend to children in foster care but are not focused
on them.[Footnote 55]
Quality Assurance Activities Can Help Monitor the Receipt of Services:
New York, Utah, Delaware, and Illinois specifically pointed to quality
assurance activities relevant to monitoring foster children's receipt
of health care services. Such activities can be used to help track the
receipt of services by individual children in foster care, including
ensuring that individual children are assessed as required and treated
appropriately. Monitoring procedures that aggregate information across
foster children can help managers ensure that health policies are
consistently implemented and having the intended results.
The four states that discussed their quality assurance activities cited
practices that included the use of technology and electronic records to
collect, analyze, and aggregate health care data, perform medical
audits, and conduct evaluations or other checks to ensure the quality
of health care services provided to children in foster care. ACF's
reviews found that states with identifiable quality assurance systems
that conformed to specific criteria had a higher percentage of cases
rated as having met the health needs of children in the states'
custody. Further, ACF's analysis suggested that states with well-
functioning quality assurance systems were more likely to succeed on
measures of enhancing a family's capacity to provide for the needs of
their children and ensuring that the children's physical and mental
health needs were being met.[Footnote 56]
The states that identified relevant quality assurance activities to us
provided examples of two approaches: (1) requiring managed care
organizations to track and report individual or aggregate data on
foster children in their care and (2) conducting medical audits of
health records for children in foster care.
With regard to requiring managed care organizations to track and report
certain data, officials in Delaware described a new requirement in its
contracts with managed care organizations aimed at ensuring that
initial health screenings occur and result in the receipt of necessary
services. In 2008, Delaware required that contracts with managed care
organizations track and report on services rendered following initial
health screenings. According to Delaware Medicaid officials, the
reports are intended to provide aggregate data on health screenings
provided. The officials told us that no specific concern triggered the
2008 quality check on initial health screenings, but officials noted
that the state would like to be able to provide aggregate data on the
percentage of children in their foster care program who received an
initial health assessment within a set number of days. Utah uses a
statewide case management system that can generate detailed data on
individual children, as well as aggregate reports. Utah officials
explained that these aggregate reports had been used to contact medical
providers when the state received alerts from the U.S. Food and Drug
Administration on the adverse effects of certain drugs. In this
instance, the state sent letters to medical providers urging them to
examine specific patients on these medications. Utah officials believed
that having a majority of records in electronic form facilitated this
effort.
Finally, one city and two states reported the use of medical audits to
ensure the receipt and quality of health care provided to children in
foster care. For example, New York City uses medical care audits to
examine the quality of services provided to the 17,000 children in the
city's foster care program.[Footnote 57] The city reported conducting
two types of medical care audits--a routine medical audit conducted
every 2 years and a special medical audit for children with HIV,
conducted at least annually. These reviews apply an audit tool that is
based on local foster care standards for physical and mental health to
assess documentation in medical records of the child's medical history,
consent for treatments, comprehensive physical examinations, diagnostic
screenings, immunization history and status, developmental and
behavioral health screenings, and the use of psychotropic medications.
Reviewers provide their results to foster care agencies, noting
findings that must be addressed immediately, as well as a corrective
action plan. The audit score is incorporated into a cumulative score on
the agency's performance. Officials in Illinois and Utah also reported
the use of medical audits to ensure the delivery of appropriate care.
ACF Offers States Health-Related Technical Assistance as Part of Its
Broader Efforts to Improve Delivery of Services:
Although states are ultimately responsible for meeting the health needs
of children in foster care, HHS is required by law to provide technical
assistance to the extent feasible to help states develop and implement
plans to improve their performance. ACF officials told us that their
emphasis is on providing technical assistance that will increase the
capacity of state child welfare agencies over the long term to serve
the needs of children in their care. ACF officials point out that they
do not expect to provide expertise in the area of health care, but
instead to help child welfare agencies carry out their mission within
the flexibility that states have.
ACF's 25 technical assistance centers--including one center that
specializes in children's mental health--offer states a range of
assistance, from on-site consultation to Web-based information on
promising practices. In some cases, the centers help state child
welfare agencies develop strategies to obtain needed services and
coordinate their efforts with others involved in health care, such as
the agencies responsible for Medicaid, public health, mental health,
and substance abuse treatment.[Footnote 58] These and other agencies
are listed among possible stakeholders in ACF's reviews of state child
welfare agencies. ACF and center staff also referred to the assistance
that is available from nonfederal sources, such as universities and
private foundations.[Footnote 59]
Technical assistance in the form of on-site consultation is provided at
state request, and few states have requested on-site consultation
specifically to address health care services for children. On-site
consultation generally is requested from ACF regions, coordinated
through the National Child Welfare Resource Center for Organizational
Improvement, and tracked by ACF through a dedicated data system. The
centers we contacted generally report that they have not been asked to
provide consultants on site, but have provided other forms of
assistance related to the health care needs of children in foster
care.[Footnote 60]
Table 4 provides summary information on the centers in ACF's network
that either specialize in an aspect of health care or have reported
providing some assistance on health care practices through 2008,
including one center with funding from HHS's SAMHSA that focuses on
children's mental health.[Footnote 61] Examples of some of the work
these centers perform in relation to health care are discussed below.
Table 4: Centers in ACF's Training and Technical Assistance Network
That Have Provided Assistance Related to Foster Children's Health Care
through 2008:
Name of center: Center specializing in aspects of health care: National
Technical Assistance Center for Children's Mental Health; Web site
address: [hyperlink, http://gucchd.georgetown.edu/];
ACF funds in 2008: Center specializing in aspects of health care: $
350,000[A];
SAMHSA funds in 2008: Center specializing in aspects of health care:
$3,050,000.
Name of center: Centers with other responsibilities that report having
assisted with health care practices: National Resource Center for
Family-Centered Practice and Permanency Planning;
Web site address: Center specializing in aspects of health care:
[hyperlink, http://www.nrcfcppp.org];
ACF funds in 2008: Center specializing in aspects of health care:
1,270,000;
SAMHSA funds in 2008: Center specializing in aspects of health care:
None.
Name of center: Centers with other responsibilities that report having
assisted with health care practices: National Child Welfare Resource
Center for Organizational Improvement;
Web site address: Center specializing in aspects of health care:
[hyperlink, http://www.nrcoi.org];
ACF funds in 2008: Center specializing in aspects of health care:
1,750,000;
SAMHSA funds in 2008: Center specializing in aspects of health care:
None.
Name of center: Centers with other responsibilities that report having
assisted with health care practices: National Child Welfare Resource
Center for Youth Development;
Web site address: Center specializing in aspects of health care:
[hyperlink, http://www.nrcys.ou.edu/yd];
ACF funds in 2008: Center specializing in aspects of health care:
1,250,000;
SAMHSA funds in 2008: Center specializing in aspects of health care:
None.
Name of center: Centers with other responsibilities that report having
assisted with health care practices: Child Welfare Information Gateway;
Web site address: Center specializing in aspects of health care:
[hyperlink, http://www.childwelfare.gov];
ACF funds in 2008: Center specializing in aspects of health care:
7,982,000;
SAMHSA funds in 2008: Center specializing in aspects of health care:
None.
Source: GAO analysis of ACF information.
[A] $200,000 is for assistance to recipients of a discretionary grant
to implement systems of care, only some of which are state agencies.
[End of table]
The center that specializes in aspects of children's health care is the
National Technical Assistance Center for Children's Mental Health,
based at Georgetown University, which helps states and other entities
build systems to improve access and outcomes for all children with
mental health concerns. The center's focus is on children who have or
are at risk of having emotional disorders, including children in foster
care. This focus has been extended to include youth facing mental
health problems who have also become involved with substance abuse. The
center's services range from the development and dissemination of
various publications to consultation on how to increase a state's
capacity to meet children's mental health needs.[Footnote 62]
Specifically, at state request, center staff and consultants may work
for a year or more with mental health leaders in individual states,
often along with child welfare directors, to help these states identify
and implement strategies to improve services for children. One staff
position at the center has been reserved for a consultant with child
welfare expertise. According to center staff, the center provides this
type of consultation to an average of 8 to10 states each year and has
served 22 states through 2008.[Footnote 63] To reach more agency
personnel, the center holds a training institute every other year for
approximately 2,000 to 2,500 attendees that in 2008 offered a series of
sessions on partnerships between mental health and child welfare
agencies for assessment, early intervention and treatment, support
services, and care coordination, among other topics. In carrying out
their work, center officials reported coordinating closely with other
federally funded centers and organizations, state professional
associations, private foundations, and research groups.[Footnote 64]
While currently focused primarily on mental health, the center is also
concerned with the integration of primary care and mental health, and
prior to implementation of the ACF reviews, received funds from the
Maternal and Child Health Bureau of HHS's HRSA to examine promising
approaches to providing the full range of health care services for
children in foster care. A series of reports were published detailing
these approaches that continue to be available through this and other
technical centers for use by child welfare agencies in improving their
service delivery.[Footnote 65]
In several other centers, staff described information that they have
provided on health care practices, including the following examples:
* Seven audio conferences on topics, such as the use of psychotropic
medications, assessing and treating children up through age 3, and
other issues concerning the mental health of children in foster care
were developed by the National Resource Center for Family-Centered
Practice and Permanency Planning at New York's Hunter College School of
Social Work. Among many sample areas of technical assistance, the
center lists health and mental health issues for children and youth in
foster care, and to that end, hosts a Webpage devoted to health care
with multiple links to other relevant sites.
* Sessions regarding the role of clinics dedicated to assessing and
treating children in foster care and the options for financing mental
health care were featured at the 2007 annual conference for child
welfare agency staff arranged by the National Child Welfare Resource
Center for Organizational Improvement at the University of Maine.
* The sharing of information on the steps states are taking to extend
Medicaid coverage to older youth when they leave foster care is a key
area of focus for the National Child Welfare Resource Center for Youth
Development in Oklahoma. The center connects states that have been
successful in this area with states asking for assistance and maintains
a list serve for state child welfare agency officials who are
responsible for helping youth prepare for independence.
ACF regional and central office staff may also share promising
practices that they observe during reviews of state programs. These
practices are posted to an ACF Web site and include several related to
child and family wellbeing.[Footnote 66] ACF's Web site notes that the
Children's Bureau does not make any representations pertaining to the
effectiveness of the posted approaches, and ACF officials stated they
had taken no further steps to share them and that they had not
evaluated specific state practices. Other practices have been shared
among states at regional meetings, as in ACF Region VII, where Kansas
shared information on its medical passport. Regional staff may also
share information on various practices adopted by states within the
regions. For example, ACF reported that regional staff members have
shared strategies for meeting children's dental needs, such as using
hygienists in Kansas and using a traveling dental van in Missouri.
Florida officials reported that they received assistance from ACF on
referrals to early intervention programs. New York and Utah officials
also acknowledged the help that they received from regional ACF
staff.[Footnote 67]
To assist in states' efforts to implement improvement strategies, ACF
newly funded five centers in fall 2008 that are expected to provide in-
depth, long-term consultation and support to states to improve the
quality and effectiveness of their child welfare services starting in
July 2009. ACF expects the assistance to help build partnerships to
deliver a broad array of integrated services that can be individually
tailored to meet the diverse needs of children and families served by
child welfare agencies, including their physical, mental, and
developmental needs as appropriate. As with the older centers, states'
identification of needs and potential strategies will determine the
assistance provided. Some assistance with aspects of health care may be
available from these centers if states request it, according to ACF
officials.
Agency Comments and Our Evaluation:
We provided a draft of this report to the Department of Health and
Human Services for comment and received a written response, which is
included in this report as appendix II. HHS provided some additional
information on its technical assistance to state foster care agencies,
particularly through collaboration between ACF and SAMHSA, to assist
states in addressing mental health and substance abuse issues among
foster children. The agency also provided technical comments, which we
have incorporated as appropriate.
We are sending copies of this report to the Secretary of Health and
Human Services, state child welfare agencies, and other interested
parties. We will provide copies to others on request. In addition, this
report is available at no charge on the GAO Web site at [hyperlink,
http://www.gao.gov].
If you or your staff have questions about this report, please contact
Kay E. Brown at (202) 512-3674 or brownke@gao.gov or Cynthia A.
Bascetta at (202) 512-7114 or bascettac@gao.gov. Contact points for our
Offices of Congressional Relations and Public Affairs may be found on
the last page of this report. GAO staff members who made key
contributions to this report are also listed in appendix III.
Sincerely yours,
Signed by:
Kay Brown:
Director Education, Workforce and Income Security Issues:
Cynthia A. Bascetta:
Director Health Care Issues:
[End of section]
Appendix I: Selection of States and Practices for GAO Review:
Our study had four objectives. These included describing practices that
selected states have adopted to address the challenges of (1)
identifying health care needs, (2) ensuring delivery of appropriate
health services, and (3) documenting and monitoring the health care of
children in foster care. In addition, we describe technical assistance
the Department of Health and Human Services' Administration for
Children and Families (ACF) provides to states to help improve their
performance in providing for the health care needs of these children.
To gain an initial understanding of the types of practices states have
adopted, we reviewed relevant reports and interviewed various experts
and researchers. We reviewed information on promising practices listed
on ACF's Web site that were identified during ACF's reviews of state
performance and a list of state practices that ACF provided to us. We
also interviewed several prominent child welfare experts and
researchers, including individuals affiliated with the American Academy
of Pediatrics, the Center for Health Care Strategies, the Chapin Hall
Center for Children, the Georgetown University Child Development
Center, and the National Academy for State Health Policy to obtain
additional information on practices to improve the delivery of health
care to children in foster care.
To update information on practices described in available publications
and to obtain additional examples that may not have been reported in
publications, we e-mailed requests for information on current practices
they believed were noteworthy efforts to address children's health care
needs to representatives of child welfare agencies in 50 states and the
District of Columbia. To minimize the burden on state representatives,
we suggested that they could limit the number of practices they
described. We sent our e-mail requests in October 2007, and
representatives for 42 of the 51 child welfare agencies provided
responses.
To gather more detailed examples of these practices, we selected 10
state child welfare agencies for further review--conducting visits to 3
states and telephone interviews with 7. In selecting states and their
practices for further review, we considered descriptions of each
state's practices obtained from the states and other research. For
practical reasons, in order to collect sufficient examples from each
category while limiting the number of distinct states we would contact,
we also considered whether a state had more than one practice it
considered noteworthy and whether it encompassed practices in at least
two of our five broad categories. We also gave some weight to the level
of context and information the state had provided about its practices
and generally limited our consideration of practices to those that
states indicated they had begun to implement. In addition, we made
efforts to include states that had achieved a strong rating on the ACF
reviews for children's physical and mental health indicators and to
achieve some distribution in geographic location and administrative
structure.
For 3 of the 10 states selected--Illinois, New York, and Utah--we
conducted site visits and interviewed officials of state child welfare
agencies and state Medicaid Offices, and when possible, health care
providers, interest groups, and foster care parents. For seven states-
-California, Delaware, Florida, Massachusetts, Oklahoma, Texas, and
Washington--we conducted interviews by telephone with officials of each
state's child welfare agency and, in some instances, officials of state
Medicaid Offices.
Key characteristics of the selected states are shown in table 5.
Collectively, the states we contacted account for 53 percent of federal
IV-E funds distributed in fiscal year 2007.
Table 5: Characteristics of States Contacted for GAO's Review:
States GAO selected: Sites visited: Ill;
Foster care caseload Sept. 30, 2007: 16,000;
Federal foster care funds 2007 (IV-E): $199,758,813;
State match required for IV E and XIX: 50.00;
Federal child welfare services funds 2007 (IV-B1): $11,343,733;
Type of child welfare administration: State;
Medicaid included in same State agency as child welfare: No;
Public, maternal & child health in same agency as child welfare: No;
Strength in physical health Per ACF review: No;
Strength in mental health per ACF review: No.
States GAO selected: Sites visited: NY;
Foster care caseload Sept. 30, 2007: 30,548;
Federal foster care funds 2007 (IV-E): 370,648,137;
State match required for IV E and XIX: 50.00;
Federal child welfare services funds 2007 (IV-B1): 14,424,182;
Type of child welfare administration: County;
Medicaid included in same State agency as child welfare: No;
Public, maternal & child health in same agency as child welfare: No;
Strength in physical health Per ACF review: Yes;
Strength in mental health per ACF review: No.
States GAO selected: Sites visited: Utah;
Foster care caseload Sept. 30, 2007: 2,600;
Federal foster care funds 2007 (IV-E): 19,232,449;
State match required for IV E and XIX: 29.86;
Federal child welfare services funds 2007 (IV- B1): 3,368,524;
Type of child welfare administration: State;
Medicaid included in same State agency as child welfare: No;
Public, maternal & child health in same agency as child welfare: No;
Strength in physical health Per ACF review: Yes;
Strength in mental health per ACF review: Yes.
States GAO selected: Sites contacted by teleconference: Calif;
Foster care caseload Sept. 30, 2007: 78,282;
Federal foster care funds 2007 (IV-E): 1,302,357,112;
State match required for IV E and XIX: 50.00;
Federal child welfare services funds 2007 (IV-B1): 33,565,519;
Type of child welfare administration: County;
Medicaid included in same State agency as child welfare: Yes;
Public, maternal & child health in same agency as child welfare: Yes;
Strength in physical health Per ACF review: Yes;
Strength in mental health per ACF review: No.
States GAO selected: Sites contacted by teleconference: Del;
Foster care caseload Sept. 30, 2007: 970;
Federal foster care funds 2007 (IV-E): $5,737,528;
State match required for IV E and XIX: 50.00;
Federal child welfare services funds 2007 (IV- B1): 783,771;
Type of child welfare administration: State;
Medicaid included in same State agency as child welfare: No;
Public, maternal & child health in same agency as child welfare: Yes;
Strength in physical health Per ACF review: Yes;
Strength in mental health per ACF review: Yes.
States GAO selected: Sites contacted by teleconference: Fla;
Foster care caseload Sept. 30, 2007: 26,124;
Federal foster care funds 2007 (IV-E): 152,407,545;
State match required for IV E and XIX: 41.24;
Federal child welfare services funds 2007 (IV-B1): 15,930,592;
Type of child welfare administration: County;
Medicaid included in same State agency as child welfare: No;
Public, maternal & child health in same agency as child welfare: No;
Strength in physical health Per ACF review: No;
Strength in mental health per ACF review: No.
States GAO selected: Sites contacted by teleconference: Mass;
Foster care caseload Sept. 30, 2007: 10,000;
Federal foster care funds 2007 (IV-E): 64,838,028;
State match required for IV E and XIX: 50.00;
Federal child welfare services funds 2007 (IV-B1): 4,094,353;
Type of child welfare administration: State;
Medicaid included in same State agency as child welfare: Yes;
Public, maternal & child health in same agency as child welfare: No;
Strength in physical health Per ACF review: No;
Strength in mental health per ACF review: No.
States GAO selected: Sites contacted by teleconference: Okla;
Foster care caseload Sept. 30, 2007: 12,200;
Federal foster care funds 2007 (IV-E): 42,892,775;
State match required for IV E and XIX: 31.26;
Federal child welfare services funds 2007 (IV-B1): 1,891,061;
Type of child welfare administration: State;
Medicaid included in same State agency as child welfare: No;
Public, maternal & child health in same agency as child welfare: No;
Strength in physical health Per ACF review: No;
Strength in mental health per ACF review: No.
States GAO selected: Sites contacted by teleconference: Tex;
Foster care caseload Sept. 30, 2007: 18,000;
Federal foster care funds 2007 (IV-E): 216,799,611;
State match required for IV E and XIX: 39.22;
Federal child welfare services funds 2007 (IV-B1): 25,115,256;
Type of child welfare administration: State;
Medicaid included in same State agency as child welfare: Yes;
Public, maternal & child health in same agency as child welfare: Yes;
Strength in physical health Per ACF review: No;
Strength in mental health per ACF review: No.
States GAO selected: Sites contacted by teleconference: Wash;
Foster care caseload Sept. 30, 2007: 11,015;
Federal foster care funds 2007 (IV-E): 84,681,985;
State match required for IV E and XIX: 49.88;
Federal child welfare services funds 2007 (IV-B1): 5,313,865;
Type of child welfare administration: State;
Medicaid included in same State agency as child welfare: Yes;
Public, maternal & child health in same agency as child welfare: Yes;
Strength in physical health Per ACF review: No;
Strength in mental health per ACF review: No.
States GAO selected: Total;
Federal foster care funds 2007 (IV-E): $4,669,165,598.
Source: GAO analysis of federal and state child welfare data.
[End of table]
For our visits and telephone interviews, we developed semistructured
interview guides for state and local child welfare agencies, including
caseworkers, state Medicaid offices, interest groups, and foster
parents. In addition, we obtained from officials of state child welfare
agencies detailed information on their identified practices, including
the dates of operation; numbers of children served; size of
jurisdiction covered; variety of services offered; funding mechanisms
used; outcomes, if any, reported; and whether any evaluative studies
had been conducted or other documents prepared that discussed the
effectiveness of the practice.
We conducted our work from November 2007 to January 2009 in accordance
with all sections of GAO's Quality Assurance Framework that are
relevant to our objectives. The framework requires that we plan and
perform the engagement to obtain sufficient and appropriate evidence to
meet our stated objectives and to discuss any limitations in our work.
We believe that the information and data obtained, and the analysis
conducted, provide a reasonable basis for any findings and conclusions.
[End of section]
Appendix I: Comments from the Department of Health and Human Services:
Department Of Health & Human Services:
Office Of The Secretary:
Assistant Secretary for:
Washington, DC 20201:
Kay E. Brown, Director:
Education, Workforce, and Income Security Issues:
U.S. Government Accountability Office:
441 G Street NW:
Washington, DC 20548:
Dear Ms. Brown:
Enclosed are the Department's comments on the U.S. Government
Accountability Office's (GAO) draft report entitled: "Foster Care:
State Practices for Assessing Health Needs, Facilitating Service
Delivery, and Monitoring Children's Care (GAO-09-26). The Department
appreciates the opportunity to review and comment on this report before
its publication.
Sincerely,
Signed by:
Craig Burton:
Acting Assistant Secretary for Legislation:
Attachment:
Department Of Health & Human Services:
Administration For Children And Families:
Office of the Assistant Secretary, Suite 600:
370 L'Enfant Promenade, S.W.:
Washington, DC— 20447:
January 9, 2009:
To: Vincent J. Ventimiglia, Jr.:
Assistant Secretary for Legislation:
From: Daniel C. Schneider:
Acting Assistant Secretary for Children and Families:
Subject: Government Accountability Office (GAO) Draft Report Titled,
"Foster Care: State Practices for Assessing Health Needs, Facilitating
Service Delivery, and Monitoring Children's Care" (GAO-09-26)
Attached are comments of the Administration for Children and Families
and the Substance Abuse and Mental Health Services Administration on
the above-referenced report.
Should you have questions or need additional information, please
contact Christine Calpin, Associate Commissioner, Children's Bureau,
Administration on Children, Youth and Families, at 202-205-8618.
Attachment:
Comments Of The Administration For Children And Families And The
Substance Abuse And Mental Health Services Administration On The
Government Accountability Office Draft Report Titled, "Foster Care:
State Practices For Assessing Health Needs, Facilitating Service
Delivery, And Monitoring Children's Care" (GAO-09-26):
The Administration for Children and Families (ACF) and the Substance
Abuse and Mental Health Services Administration (SAMHSA) appreciate the
opportunity to comment on the Government Accountability Office (GAO)
draft report.
GAO Recommendations:
GAO did not make any recommendations in this report.
In describing the National Technical Assistance Center for Children's
Mental Health (Georgetown), GAO did not mention that part of the
funding for this center (i.e., $150,000) comes from an Interagency
Agreement with ACF. The report states, "One staff position at the
center has been reserved for a consultant with child welfare
expertise." This is accomplished through the Interagency Agreement
between SAMHSA and ACF. This should be stated.
There is no mention that the SAMHSA-funded Technical Assistance
Partnership also has a staff position for a child welfare consultant
that provides assistance to SAMHSA-funded system of care communities
that are part of the Comprehensive Community Mental Health for Children
and Their Families Program. This staff position is similarly funded
through an Interagency Agreement with ACF in the amount of $200,000,
which makes the total Interagency Agreement $350,000. This position and
the relationship established with ACF has allowed SAMHSA to prioritize
services and consultation related to child welfare issues.
As a result of the collaboration between SAMHSA and ACF, and the
significant mental health needs of foster children, SAMHSA has made the
child welfare population a priority in the Request for Application
(RFA) used to solicit proposals for the Comprehensive Community Mental
Health for Children and Their Families Program. Specifically, page 2 of
the RFA states that applicants are encouraged to address children and
youth involved with the child welfare system. Creating priority status
for children and youth in the child welfare system has resulted in a
number of grantees that specifically focus on foster children, which
has helped create collaborations and partnerships between mental health
and child welfare systems in States and communities across the nation.
Of the 59 currently funded system of care grantees, 7 have a primary
focus on foster children.
While SAMHSA manages this Center, ACF is a significant fund provider of
the Center's activities. Similar to the other technical assistance
centers funded by ACF, NCSACW does not provide direct medical services,
but provides assistance to agencies supporting positive child welfare
outcomes.
NCSACW completed a review of the Round 1 Child and Family Services
Reviews (CFSRs) and Program Improvement Plans, managed by ACF, and
found that 13 of the States specifically mentioned that services were
inadequate to meet the substance abuse treatment needs of adolescents
in their caseloads. Although not specifically mentioned in reports-from
other States, this is likely to be a much more widely experienced
problem.
[End of section]
Appendix II: GAO Contacts and Staff Acknowledgments:
GAO Contacts:
Kay E. Brown, (202) 512-3674 or brownke@gao.gov Cynthia A. Bascetta,
(202) 512-7114 or bascettac@gao.gov:
Staff Acknowledgments:
In addition to the contacts named above, Betty Ward-Zukerman and
Carolyn L. Yocom (Assistant Directors), Patricia Elston, Carolyn Feis
Korman, Jacqueline Harpp, Darryl Joyce, Jasleen Modi, Alexandra
Edwards, Alison Goetsch, Kevin Milne, Mimi Nguyen, James Rebbe, Jay
Smale, and Charlie Willson made key contributions to this report.
[End of section]
Related GAO Products:
Medicare Physician Payment: Care Coordination Programs Used in
Demonstration Show Progress, but Wider Use of Payment Approach May Be
Limited. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-65].
Washington, D.C.: February 15, 2008.
Department of Health and Human Services, Centers for Medicare and
Medicaid Services: Medicaid Program; Elimination of Reimbursement Under
Medicaid for School Administration Expenditures and Costs Related to
Transportation of School-Age Children Between Home and School.
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-394R]. Washington,
D.C.: January 11, 2008.
Child Welfare: Additional Federal Action Could Help States Address
Challenges in Providing Services to Children and Families. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-07-850T]. Washington, D.C.: May
15, 2007.
Medicaid: Concerns Remain about Sufficiency of Data for Oversight of
Children's Dental Services. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-07-826T]. Washington, D.C.: May 2, 2007.
Pediatric Drug Research: Studies Conducted Under Best Pharmaceuticals
for Children Act. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-07-
557]. Washington, D.C.: March 22, 2007.
Children's Health Insurance: States' SCHIP Enrollment and Spending and
Considerations for Reauthorization. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-07-558T]. Washington, D.C.: March 1, 2007.
Child Welfare: Improving Social Service Program, Training, and
Technical Assistance Information Would Help Address Long-standing
Service-Level and Workforce Challenges. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-07-75]. Washington, D.C.: October
6, 2006.
Foster Care and Adoption Assistance: Federal Oversight Needed to
Safeguard Funds and Ensure Consistent Support for States'
Administrative Costs. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-
06-649]. Washington, D.C.: June 15, 2006.
Administrative Expenditures and Federal Matching Rates of Selected
Support Programs. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-05-
839R]. Washington, D.C.: June 30, 2005.
Medicaid Financing: States' Use of Contingency-Fee Consultants to
Maximize Federal Reimbursements Highlights Need for Improved Federal
Oversight. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-05-748].
Washington, D.C.: June 28, 2005.
Medicaid: States' Efforts to Maximize Federal Reimbursements Highlight
Need for Improved Federal Oversight. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-05-836T]. Washington, D.C.: June 28, 2005.
Child And Family Services Reviews: States and HHS Face Challenges in
Assessing and Improving State Performance. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-04-781T]. Washington, D.C.: May
13, 2004.
Child And Family Services Reviews: Better Use of Data and Improved
Guidance Could Enhance HHS's Oversight of State Performance.
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-04-333]. Washington,
D.C.: April 20, 2004.
Medicaid and SCHIP: States' Premium and Cost Sharing Requirements for
Beneficiaries. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-04-
491]. Washington, D.C.: March 30, 2004.
SCHIP: HHS Continues to Approve Waivers That Are Inconsistent with
Program Goals. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-04-
166R]. Washington, D.C.: January 5, 2004.
Child Welfare: States Face Challenges in Developing Information Systems
and Reporting Reliable Child Welfare Data. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-04-267T]. Washington, D.C.:
November 19, 2003.
Child Welfare: Most States Are Developing Statewide Information
Systems, but the Reliability of Child Welfare Data Could Be Improved.
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-03-809]. Washington,
D.C.: July 31, 2003.
Child Welfare and Juvenile Justice: Federal Agencies Could Play a
Stronger Role in Helping States Reduce the Number of Children Placed
Solely to Obtain Mental Health Services. [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-03-397]. Washington, D.C.: April
21, 2003.
Medicaid and SCHIP: States Use Varying Approaches to Monitor Children's
Access to Care. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-03-
222]. Washington, D.C.: January 14, 2003.
Mental Health Services: Effectiveness of Insurance Coverage and Federal
Programs for Children Who Have Experienced Trauma Largely Unknown.
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-02-813]. Washington,
D.C.: August 22, 2002.
Medicaid and SCHIP: States' Enrollment and Payment Policies Can Affect
Children's Access to Care. [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-01-883]. Washington, D.C.: September 10, 2001.
Medicaid: Stronger Efforts Needed to Ensure Children's Access to Health
Screening Services. [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-
01-749]. Washington, D.C.: July 13, 2001.
Foster Care: Health Needs of Many Young Children Are Unknown And Unmet.
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO/HEHS-95-114].
Washington, D.C.: May 26, 1995.
[End of section]
Footnotes:
[1] Medicaid is a federal-state health financing program established in
1965 to provide health care coverage to certain categories of low-
income adults and children.
[2] For example, federal law requires that states have standards to
ensure children in foster care are provided quality services to protect
their safety and health. In addition, states must maintain case plans
for children that include health records, including the most recent
information available regarding their immunizations, known medical
problems, medications, and their health providers' names and addresses.
[3] Pub. L. No. 110-351 (2008).
[4] Throughout the report, we use the term "health" to refer to both
physical and mental health. Physical health includes dental health.
Other health areas included are those dealing with children's
development and with substance abuse.
[5] As part of our process to select states, we asked all state child
welfare agencies to identify some practices that they had adopted and
considered noteworthy to screen and assess needs, facilitate and
coordinate access to care, or manage data and information. We received
42 responses. While most of the 10 states reported having multiple
practices, we did not cover all of these practices adopted by each
state.
[6] While states have primary responsibility for the welfare of
children in their care, this responsibility has been delegated to
county agencies in about one-fifth of the states, including many of the
nation's most populous states such as California, Florida, and New
York.
[7] Data for federal fiscal year 2006 were the most recent available.
The proportion of children who meet federal eligibility criteria has
decreased over the past decade since the income criteria are set at the
1996 income levels under the former Aid to Families with Dependent
Children program. See GAO, Foster Care and Adoption Assistance: Federal
Oversight Needed to Safeguard Funds and Ensure Consistent Support for
States' Administrative Costs, [hyperlink,
http://www.gao.gov/products/GAO-06-649] (Washington, D.C.: June 15,
2006).
[8] Included are IV-E funds available to states to reimburse up to 50
percent of their IV-E administrative costs for child placement,
information systems, and other purposes and up to 75 percent of their
IV-E training costs. (45 C.F.R. § 1356.60(b) and (c))
[9] States may also use other federal funds, such as the title XX
Social Services Block Grant or Temporary Assistance to Needy Families,
to provide some child welfare services.
[10] Title IV-B includes two different programs: subpart 1 for general
child welfare services and subpart 2 for family preservation, family
support, time-limited family reunification, and adoption promotion and
support services. Some of the funds available under subpart 2 may be
used for health care services, such as counseling, mental health, and
substance abuse treatment for foster children or their families, during
the 15 months following the children's entry into foster care in order
to facilitate the timely, safe reunification of these foster children
with their families.
[11] Child and Family Services Improvement Act of 2006, Pub. L. No.
109- 288 (2006).
[12] Fostering Connections to Success and Increasing Adoptions Act of
2008, Pub. L. No. 110-351 (2008). ACF alerted states to this new
requirement but did not issue further instructions in 2008.
[13] ACF's reviews examined a sample of the case records of children
served by state agencies; children in foster care, the focus of GAO's
work, were a subset of this sample.
[14] In the initial round of CFSRs, ACF designated a state as showing
strength when 85 percent of the up to 65 case records examined in that
state indicated that the state had assessed needs and provided
treatment as appropriate. Depending on the state, the results varied
widely, with the percentage of sampled children who were not assessed
or treated ranging from 8 percent to 49 percent. In the next round of
reviews, occurring from 2007 through 2010, states will have to assess
and treat 90 percent of cases examined in order to show strengths and
95 percent of cases in order to be deemed in substantial conformity.
[15] In November 2008, ACF reported that 39 states had achieved their
planned goals and action steps, including those for children's health;
that 7 states had missed their planned goals and action steps and were
subject to withholding of federal grant funds; and that the actions of
6 states were still being evaluated. ACF withheld grant funds from one
state that did not complete the action steps for improving children's
health. See 45 C.F.R. § 1355.36 for regulations governing the
withholding of grant funds.
[16] In addition to Medicaid, federal funds are available to states for
health-related services for a population that may include children in
foster care under title V of the Social Security Act for maternal and
child health, under title XIX of the Public Health Service Act for
community mental health centers, and under the Individuals with
Disabilities Education Act.
[17] See 42 U.S.C. § 1396a(a)(10)(A)(i)(I).
[18] The Urban Institute reports that all states have extended Medicaid
coverage to children in foster care. See Rob Geen, Anna Sommers, and
Mindy Cohen, The Urban Institute, Medicaid Spending on Foster Children
(Washington, D.C., 2005). However, some children are excluded, such as
noncitizens, those with private health insurance, and children who
leave foster care while they are on trial visits to their homes.
[19] This represents federal and state dollars combined for the most
recent year available. Expenditures for children in foster care are
likely to be underestimated and may exclude expenditures for some
children participating in foster care.
[20] Fee-for-service arrangements may also include primary care case
management, where primary care providers are paid a monthly, per capita
case management fee, usually around $3, to coordinate care for
beneficiaries, in addition to fee-for-service reimbursement for any
health care services they provide. Coordination may involve referrals
to specialists and other providers.
[21] See 42 U.S.C. §§ 1396a(a)(43), 1396d(a)(4)(B).
[22] See 42 C.F.R. § 441.50 et seq.
[23] For example, The Urban Institute reported that 38 states funded
targeted case management under Medicaid for children in foster care.
See Rob Geen, Anna Sommers, and Mindy Cohen, The Urban Institute,
Medicaid Spending on Foster Children, (Washington, D.C., 2005).
[24] See 42 U.S.C. §§ 1396(a)(25), 1396n(g)(4).
[25] We reported that most states have used contingency-fee consultants
to help implement a wide range of projects, including rehabilitative
and targeted case management services, to maximize federal Medicaid
reimbursements. In particular, we found that during fiscal years 1999
through 2003, combined state and federal spending for one category of
Medicaid services--targeted case management--increased by 76 percent,
from $1.7 billion to $3 billion, across all states. See GAO, Medicaid
Financing: States' Use of Contingency-Fee Consultants to Maximize
Federal Reimbursements Highlight Need for Improved Federal Oversight,
[hyperlink, http://www.gao.gov/products/GAO-05-748] (Washington, D.C.:
June 28, 2005).
[26] The Deficit Reduction Act of 2005 amended the Social Security Act
provisions concerning Medicaid coverage for case management and
targeted case management services effective January 1, 2006. See Pub.
L. No. 109-171, §6052, 120 Stat. 4, 93-95.
[27] See Medicaid Program; Optional State Plan Case Managed Services
(72 Fed. Reg. 68077, December 4, 2007); and Medicaid Program; Coverage
for Rehabilitative Services (72 Fed. Reg. 45201, August 13, 2007).
[28] Supplemental Appropriations Act, 2008, Pub. L. No. 110-252,
§7001(a), 122 Stat. 2323, 2387-88.
[29] Organizations such as the American Academy of Pediatrics, the
American Academy of Child and Adolescent Psychiatry, and the Child
Welfare League of America recommend assessments for children shortly
after children enter foster care. However, to avoid undue burden on
children and providers, both Delaware and New York consider that
assessments made prior to entry into foster care may suffice.
[30] Laurel K. Leslie, Michael S. Hurlburt, John Landsverk et al.,
"Comprehensive Assessments for Children Entering Foster Care: A
National Perspective," Pediatrics, 112 (1) (2003), pp. 134-142.
(Accessible via [hyperlink,
http://www.pediatrics.org/cgi/content/full/112/1/134].) Also see N.
Halfon, A. Zepeda, and M. Inkelas (2002), Mental Health Services for
Children in Foster Care (Policy Brief Number 4). Los Angeles: UCLA
Center for Healthier Children, Families and Communities.
[31] A.C. Stahmer, L.K. Leslie, J. A. Landsverk et al., "Developmental
Services for Young Children in Foster Care: Assessment and Service
Delivery," Journal of Social Service Research, 33 (2) (2006), pp. 27-
38.
[32] Florida requires the initial screening within 72 hours; New York
recommends but does not require that its counties and agencies provide
an initial screening.
[33] California has no policy on initial screenings, but some of its
counties conduct examinations that are similar. Texas's contract with
its health providers requires that children newborn to age 3 receive an
exam within 14 days of enrollment in the health plan and that older
children receive an exam within 21 days. A dental exam must be provided
within 60 days for children age 1 or older. Providers may be penalized
financially if they do not meet these timelines for certain percentages
of children. Washington's assessment process must be completed within
30 days of entry into foster care for children who are expected to
remain in out-of-home placement longer than 30 days.
[34] Such a policy may involve separate child welfare and Medicaid
requirements. For example, Massachusetts officials indicated that the
state child welfare agency has a policy specifying that foster parents
schedule and support subsequent health care screenings of the foster
children in their care. The Massachusetts Medicaid agency requires that
Medicaid providers perform ongoing screenings which follow the
standards set by the state Medicaid agency for EPSDT screens.
[35] See Administration for Children and Families, Office of Planning,
Research, and Evaluation, National Survey of Child and Adolescent Well-
Being Research Brief No. 7: Special Health Care Needs among Children in
Child Welfare, Research Brief, Findings from the NSCAW Study (2008).
[36] See Jan McCarthy and others, National Technical Assistance Center
for Children's Mental Health and Technical Assistance Partnership for
Child, and Family Mental Health, Child and Family Services Reviews 2001-
2004--A Mental Health Analysis (Washington, D.C., August 2007), p. 14.
[37] See P. K. Jaudes, L. A. Bilaver, R. M. George and others,
"Improving Access to Health Care for Foster Children: The Illinois
Model," Child Welfare, 83 (3) (2004), 215-238; and S. M. Horowitz, P.
Owens, and M. D. Simms, "Specialized Assessments for Children in Foster
Care," Pediatrics, 106 (2000), 59-66 (available at [hyperlink,
http://www.pediatrics.org/cgi/content/full/106/1/59], accessed on
November 18, 2008).
[38] P.K. Jaudes and others "Improving Access to Health Care for Foster
Children: The Illinois Model," Child Welfare, 83 (3) (2004), 215-238.
[39] See L. K. Leslie and others "Comprehensive Assessments for
Children Entering Foster Care: A National Perspective", Pediatrics, 112
(1)(2003), pp. 134-142. (Accessible via [hyperlink,
http://www.pediatrics.org/cgi/content/full/112/1/134].), or S. M.
Horowitz, P. Owens, and M.D. Simms, "Specialized Assessments for
Children in Foster Care," Pediatrics, 106 (2000), 59-66 (available at
[hyperlink, http://www.pediatrics.org/cgi/content/full/106/1/59],
accessed on November 18, 2008).
[40] State officials reported that in 2008, the agency funded 45 full-
time equivalent social worker positions to assess children, with at
least one social worker in each of the state's 44 child welfare
offices. Each social worker was responsible for assessing approximately
12 to 14 children each month and entering the results into the state's
child welfare case management system.
[41] For all children covered by Medicaid, not just those in foster
care, state officials told us that Illinois also has a performance
payment of $30 per child per year if a required number of visits is
met, as well as an expedited payment process that returns payment
within 30 days. Additionally, the state was implementing a pay-for-
performance bonus for serving a certain number of children.
[42] Telepsychiatry is a form of video conferencing that can facilitate
provision of psychiatric services to patients living in remote
locations or otherwise underserved areas.
[43] Rebecca Colman and others, The New York State Care Coordination
Pilot Project: Process and Impact Evaluation Study Findings, a report
for the New York State Office of Children and Family Services, March
2007.
[44] State officials told us the 2008 budget for the nursing program is
approximately $3.1 million. The majority of costs are personnel costs,
with about 46 percent paid for by federal Medicaid funds, 18 percent by
state health department funds, and 36 percent by state child welfare
department funds. These funds are used to provide services for up to
2,600 children enrolled in foster care on any given day.
[45] The two medical care management agencies in Cook County that do
not use the reminder-recall system are local health departments.
[46] Colman et. al., The New York State Care Coordination Pilot
Project: Process and Impact Evaluation Study Findings, a report for the
New York State Office of Children and Family Services, March 2007.
[47] Psychotropic medications may have more than one purpose and may be
used to treat other medical conditions. For example, the same drug may
be used to control seizures for someone with epilepsy and to reduce
mood swings in someone with bipolar disorder.
[48] Diane L. Green, Wesley Hawkins, and Michelle Hawkins, "Medication
of Children and Youth in Foster Care," Disability Issues for Social
Workers and Human Services Professionals in the Twenty-First Century,
(New York: Haworth Press, 2005). Also see GAO, Pediatric Drug Research:
Studies Conducted under Best Pharmaceuticals for Children Act,
[hyperlink, http://www.gao.gov/products/GAO-07-557] (Washington, D.C.:
Mar. 22, 2007).
[49] Julie M. Zito and others, "Psychotropic Medication Patterns Among
Youth in Foster Care," Pediatrics, vol. 121, no. 1 (2008): e157-e163.
[50] The types of circumstances cited include the absence of a clinical
diagnosis, the concurrent use of five or more psychotropic medications,
multiple medications being used before trying just one, exceeding the
usually recommended dose, and prescribing psychotropic medications for
children less than 4 years of age.
[51] See [hyperlink,
http://www.hhsc.state.tx.us/medicaid/occ/Psychoactive_Medications.html]
(accessed on Sept. 2, 2008).
[52] The passport covers children in foster care placements, children
placed with relatives by the state, children formerly in the foster
care program who have returned home but remain in the state's custody,
and children who voluntarily entered into the state's care.
[53] See the following Web site for further information: [hyperlink,
https://www.fostercaretx.com/portal/public/fc/fostercare/health_passport
/health_passport_online_training_tools.com].
[54] The Congressional Budget Office recently noted that electronic
health records in general might help with the sharing of health
information, which in turn might improve the quality of care. See
Congressional Budget Office, Evidence on the Costs and Benefits of
Health Information Technology (May 2008).
[55] Department of Health and Human Services, Office of Inspector
General, State Medicaid Agencies' Initiatives on Health Information
Technology and Health Information Exchange, OEI-02-06-00270
(Washington, D.C., August 2007).
[56] See the Department of Health and Human Services, Administration
for Children and Families Web site, Summary of the Results of the 2001-
2004 Child and Family Services Reviews, General Findings from The
Federal Child and Family Services Review, p. 17 of 39. This is
available at [hyperlink,
http://www.acf.hhs.gov/programs/cb/cwmonitoring/results/index.htm]
(accessed on Aug. 28, 2008).
[57] According to New York officials, as of February 2008, New York
City's foster care population represented more than 80 percent of all
children in the foster care system in the state.
[58] In commenting on a draft of this report, HHS officials noted that
ACF uses an interagency agreement with the Substance Abuse and Mental
Health Services Administration to contribute to an additional technical
assistance center called the "National Center on Substance Abuse and
Child Welfare." While GAO's research identified this additional center,
the mission of the center focused on substance use in intact families
and did not specifically address foster children; therefore, this
center was not included in the scope of the GAO study.
[59] Several of the centers include links to the websites of these
other organizations. For example, the National Resource Center for
Family- Centered Practice and Permanency Planning Center provides a
link to The Commonwealth Fund for information on developmental
screening.
[60] The centers submit regular reports to ACF on their activities, but
they do not have to identify the particular assistance provided
individual states. On-site consultation to individual states, however,
must be reported by eight centers through the Technical Assistance
Tracking Internet System. As GAO has previously reported, ACF has not
independently evaluated the centers' effectiveness.
[61] The National Center on Substance Abuse and Child Welfare, operated
by the Center for Children and Family Futures, is charged with
assisting states and others to improve outcomes for families with
substance use disorders who are involved in the child welfare and
family court systems.
[62] An example of the center's recent publications is: Child and
Family Services Reviews 2001-2004 - A Mental Health Analysis, 2007,
which reports on mental health service delivery challenges and
management trends noted in ACF reviews and state improvement plans.
[63] The 22 states are Alaska, Arizona, Arkansas, Florida, Georgia,
Illinois, Indiana, Kentucky, Maryland, Minnesota, Mississippi,
Missouri, Nebraska, Nevada, New Hampshire, New Mexico, Oklahoma,
Pennsylvania, South Carolina, Tennessee, Utah, and Vermont.
[64] The center has worked closely with the Technical Assistance
Partnership for Child and Family Mental Health operated by the American
Institutes for Research with SAMHSA funding, the National Association
of State Mental Health Program Directors, The Annie E. Casey
Foundation, and the University of South Florida.
[65] See Meeting the Health Care Needs of Children in the Foster Care
System, 2002, an HRSA-sponsored publication that reported on a 3-year
study of promising approaches to meeting the physical, mental,
emotional, developmental, and dental health needs of foster children.
[66] See [hyperlink,
http://www.acf.hhs.gov/programs/cb/cwmonitoring/promise/index.htm]
(accessed on Nov. 21, 2008).
[67] For more information on ACF's technical assistance and states'
reactions, see GAO, Child and Family Services Reviews: Better Use of
Data Could Enhance HHS's Oversight of State Performance, [hyperlink,
http://www.gao.gov/products/GAO-04-333] (Washington, D.C.: Apr. 20,
2004).
GAO's Mission:
The Government Accountability Office, the audit, evaluation and
investigative arm of Congress, exists to support Congress in meeting
its constitutional responsibilities and to help improve the performance
and accountability of the federal government for the American people.
GAO examines the use of public funds; evaluates federal programs and
policies; and provides analyses, recommendations, and other assistance
to help Congress make informed oversight, policy, and funding
decisions. GAO's commitment to good government is reflected in its core
values of accountability, integrity, and reliability.
Obtaining Copies of GAO Reports and Testimony:
The fastest and easiest way to obtain copies of GAO documents at no
cost is through GAO's Web site [hyperlink, http://www.gao.gov]. Each
weekday, GAO posts newly released reports, testimony, and
correspondence on its Web site. To have GAO e-mail you a list of newly
posted products every afternoon, go to [hyperlink, http://www.gao.gov]
and select "E-mail Updates."
Order by Phone:
The price of each GAO publication reflects GAO’s actual cost of
production and distribution and depends on the number of pages in the
publication and whether the publication is printed in color or black and
white. Pricing and ordering information is posted on GAO’s Web site,
[hyperlink, http://www.gao.gov/ordering.htm].
Place orders by calling (202) 512-6000, toll free (866) 801-7077, or
TDD (202) 512-2537.
Orders may be paid for using American Express, Discover Card,
MasterCard, Visa, check, or money order. Call for additional
information.
To Report Fraud, Waste, and Abuse in Federal Programs:
Contact:
Web site: [hyperlink, http://www.gao.gov/fraudnet/fraudnet.htm]:
E-mail: fraudnet@gao.gov:
Automated answering system: (800) 424-5454 or (202) 512-7470:
Congressional Relations:
Ralph Dawn, Managing Director, dawnr@gao.gov:
(202) 512-4400:
U.S. Government Accountability Office:
441 G Street NW, Room 7125:
Washington, D.C. 20548:
Public Affairs:
Chuck Young, Managing Director, youngc1@gao.gov:
(202) 512-4800:
U.S. Government Accountability Office:
441 G Street NW, Room 7149:
Washington, D.C. 20548: